>>WELCOME BACK TO ALL OF THE
PANELISTS, PARTICIPANTS AND
DISCUSSANTS.
WE APPRECIATE ALL OF THE HARD
WORK AND DISCRETIONARY EFFORT
THAT YOU ALL HAVE SHOWED OVER
THE PAST DAY, CONTINUING ON TO
TODAY.
I THINK THAT WE HAVE HAD A VERY
RICH AND ROBUST DISCUSSION IN A
MULTIDISCIPLINARY MANNER THAT
REALLY CAPTURED SOME OF THE KEY
ISSUES, DIALOGUE, AND POTENTIAL
SOLUTIONS THAT WE WILL BE
SYNTHESIZING THIS MORNING AS WE
GO FORWARD.
IT STARTED OFF WITH A GREAT
KEYNOTE ADDRESS BY DR. SATCHER,
AND THAT REALLY KICKED OFF SOME
VERY ROBUST AND DETAILED
DISCUSSIONS ABOUT SOME OF THE
PROBLEMS THAT WE HAVE TO SORT OF
FRAME AND ADDRESS, AND THEN COME
UP WITH SOLUTIONS AS WE TRY TO
REDUCE AND ELIMINATE INEQUITIES
AND DISPARITIES IN ACUTE STROKE
CARE ACCESS AND DELIVERY.
AND WE'RE GOING TO BE HEARING
ABOUT SOME OF THOSE PROBLEMS IN
THE NEXT FEW MINUTES, AS WE GET
THE REPORTS FROM THE VARIOUS
TASK FORCE LEADERS.
LET ME TAKE A MOMENT TO
INTRODUCE MY CO-CHAIR,
DR. BENSON.
RICHARD?
>> GOOD MORNING.
YES, THANKS, DR. ALBERTS.
WE HAD A GREAT DAY YESTERDAY,
AND WE'RE EXCITED TO HEAR A
SUMMARY OF ALL OF THE
INFORMATION FROM YESTERDAY.
THANK YOU.
>> THANK YOU.
GREG, DO YOU WANT TO BRING UP
OTHER SLIDES?
OR SAM?
>> SURE.
WHAT WOULD YOU LIKE US TO START
WITH?
>> SO I THINK WE'RE GOING TO
START WITH OUR FIRST TASK FORCE,
RIGHT?
WITH OUR FIRST TIME POINT.
I SEE CHARLES AND ERIKA ARE BOTH
ON, SO IF YOU COULD BRING UP THE
PRE-HOSPITAL SLIDES, GREG?
>> SURE.
ONE MOMENT.
>> GREAT, THANK YOU.
THANKS VERY MUCH, GREG.
SO IT'S AN HONOR AND A PRIVILEGE
AGAIN FOR COMMANDER ODOM AND I
TO KIND OF PRESENT THE RESULTS
OF THE BREAKOUT ROOMS
CONVERSATIONS YESTERDAY.
OBVIOUSLY IN THE AFTERNOON
YESTERDAY, EVERYBODY WAS KIND OF
GIVEN A HIGHLIGHTS FROM HAMLET,
A SMALL GLIMMER OF WHAT THE
CONVERSATIONS WITH ALLUDING TO,
BUT TODAY WE LOOK FORWARD TO
KIND OF TAKING A DEEPER DIVE
GOING INTO THIS.
WE CAN GO TO THE NEXT SLIDE,
PLEASE, GREG.
SO FIRST AND FOREMOST, COVERING
THE GEOGRAPHY AREA, YOU KNOW,
FIRST AND FOREMOST, THERE WERE
NO CORRECTIONS OF THE ORIGINAL
DISSEMINATED DOCUMENT.
WE CAN GO TO THE NEXT SLIDE,
GREG.
AND THEN THESE WERE KIND OF THE
OUTSTANDING QUESTIONS OR GAPS
BROUGHT UP FOR CONSIDERATION.
AND FIRST WAS, AS HAS BEEN
BROUGHT UP IN SEVERAL OTHER TIME
EPOCHS AS WELL, THE EDUCATION
BARRIER FOR BOTH PROVIDERS AND
PATIENTS IN UNDERSERVED AREAS.
THEY'RE INFLUENCED, AS
DR. BENSON TALKED ABOUT
YESTERDAY, BY MULTIPLE SOCIAL
DETERMINANTS OF HEALTH.
NEXT WAS REGARDING LOGISTICAL
BARRIERS AND CHALLENGES IN
COMMUNICATION BETWEEN HOSPITALS
AND PRE-HOSPITALS FOR STROKE
SYSTEMS OF CARE AS WELL WITH
MULTIPLE DIFFERENT SPOKE SITES,
COMMUNICATION BETWEEN SPOKE
SITES AND THE IDEA OF A COMMAND
CENTER WAS AS WELL BROUGHT UP.
NEXT AS WAS TALKED ABOUT AGAIN
IN MULTIPLE GROUPS WAS THE
ESSENCE OF ARTIFICIAL STATE
BORDERS AND HOW THESE REALLY
NEED TO BE REMOVED TO OPTIMIZE
CARE IN A PATIENT-CENTERED
PHILOSOPHICAL APPROACH.
AND THEN ANOTHER ITEM WAS THE
UNEVEN COVERAGE TIMELY ACCESS TO
TELEMEDICINE AND NEUROLOGISTS,
BUT ALSO TO HIGHLIGHT THAT OF
NEUROINTERVENTIONALISTS AS WELL,
WHICH ARE CRITICAL FOR THE
STROKE SUBTYPES THAT WE TALKED
ABOUT THAT HAVE THESE LARGE
VESSEL OCCLUSIONS.
AND THEN THE NEXT POINT IS THAT
ALTHOUGH URBAN AREAS MAY BE MORE
DENSELY POPULATED, ACCESS TO
CARE MAY STILL BE AN ISSUE IN
THIS GEOGRAPHICAL AREA RELATED
TO POVERTY, CITIZENSHIP,
INSURANCE STATUS OR OTHER
MULTIFACTORIAL ISSUES.
AND THEN FINALLY, ANOTHER GAP OF
CONSIDERATION THAT MARK TALKED
ABOUT YESTERDAY WAS THE COST OF
EMS TO PATIENTS.
FOR THOSE OF YOU WHO MAY HAVE
BEEN IN AN AMBULANCE, THIS IS
CERTAINLY A BILL THAT YOU CAN
GET THAT MAY NOT BE NECESSARILY
COVERED BY INSURANCE, THAT IS
ABOVE $1,000 IF NOT A FEW
THOUSAND DOLLARS.
WE CAN GO TO THE NEXT SLIDE,
PLEASE.
AND SO THE BREAKOUT GROUP KIND
OF IDENTIFIED SEVERAL ADDITIONAL
ITEMS AS BEST PRACTICES OR
SOLUTIONS TO CONSIDER, WITH ONE
BEING TO INCENTIVIZE
PROFESSIONALS, EMS AND
PHYSICIANS TO SPECIALIZE IN
STROKE IF POSSIBLE.
AND I'LL ALSO ADD AS WELL, TO
HAVE SOME SORT OF TRAINING OR
CERTIFICATE OF TRAINING IN
STROKE.
AND FOR BACKGROUND IN THIS AREA,
MANY OF US ARE FAMILIAR WITH
ACLS TRAINING.
IT'S CONCEIVABLE THAT THE
UNIVERSITY OF MIAMI'S WORK FOR
CREATING AN ASLS, ADVANCED
STROKE LIFE SUPPORT COURSE,
COULD POTENTIALLY BE SOMETHING
THAT'S TRANSLATED TO HOSPITALS
AND CENTERS FOR ALL APPROPRIATE
STAFF TO HAVE.
NEXT IS DISCUSSION REGARDING
COMPREHENSIVE STROKE CENTERS
BEING ABLE TO GOVERN THEIR
SYSTEM OF CARE, AND INCLUDING
THE PRE-HOSPITAL DOMAIN.
AND AGAIN, SOMETHING THAT WAS
BROUGHT UP WAS THE ESSENCE OF
TALKING ABOUT A COMMAND CENTER
THAT IS INVOLVED RIGHT FROM THE
VERY BEGINNING WITH THE PATIENT
STILL IN THE PREHOSPITAL SETTING
THAT WILL HELP TO GET THAT
PATIENT AS QUICKLY AS POSSIBLE
TO THE MOST APPROPRIATE SITE
WITHIN THEIR SYSTEM.
NEXT IS, AS TECHNOLOGY AS
EVOLVED, QUALITY OF CONNECTIVITY
HAS GOTTEN BETTER, SO USING THIS
WITH AMBULANCE PARTNERS IS OF
THE UTMOST IMPORTANCE, SO NOT TO
BE IN WIFI GAP AREAS.
AND THEN -- AND THIS OBVIOUSLY
IS SOMETHING THAT PLAYS AN
IMPORTANT ROLE FOR THE
PRE-HOSPITAL TELEMEDICINE THAT
MAY BE PERFORMED.
AND THEN FINALLY, AS INCENTIVES
AND IMPLEMENTED INNOVATIONS FOR
INTERVENTIONAL TEAMS, AS WE
ALLUDED TO, TO HAVE MORE TIMELY
ACCESS TO PATIENTS.
AND THESE, AGAIN, THESE LARGE
VESSEL OCCLUSION STROKES ARE THE
ONES THAT CAN HAVE THE HIGHEST
DEATH RATES AND THE MOST SEVERE
DISABILITIES ASSOCIATED WITH
THEM.
SO THIS IS OF THE UTMOST
IMPORTANCE.
TIME IS BRAIN, AS EVERYBODY
KNOWS.
SO GETTING THESE PATIENTS TO
THESE CENTERS AS QUICKLY AS
POSSIBLE AND TO OUR
INTERVENTIONALISTS IS IMPORTANT.
AND THERE ARE A LOT OF DIFFERENT
INNOVATIVE WAYS THAT SYSTEMS MAY
IMPLEMENT THIS.
FIXED WING HAS BEEN TALKED
ABOUT, THERE'S BEEN CONVERSATION
IN SOME SYSTEMS TRANSPORTING THE
INTERVENTIONAL TEAM TO THE
PATIENT OR TO AN AREA THAT'S
CLOSER.
SO THAT'S ANOTHER POINT.
WE CAN GO TO THE NEXT SLIDE NOW.
AND THIS WILL BE A REPORT OUT OF
THE POLICY AND REGULATIONS
BREAKOUT GROUP CONVERSATION.
WE CAN GO TO THE NEXT SLIDE.
AGAIN, THERE WEREN'T ANY
CORRECTIONS OF THE ORIGINAL
DOCUMENT THAT WAS DISSEMINATED.
WE CAN GO TO THE NEXT SLIDE,
PLEASE.
AND FOR OUTSTANDING QUESTIONS OR
GAPS TO CONSIDER, AS WAS TALKED
ABOUT IN THE LARGE GROUP SESSION
AS MARK AND OTHERS BROUGHT UP,
MOBILE STROKE UNITS IS KIND OF
SOMETHING TO REALLY POTENTIALLY
FOCUS ON MORE.
WITH MANY SUBSEQUENT QUESTIONS.
WHAT IS THE FUNDING SOURCE, WHO
HAS CONTROL, WHO PARTICIPATES?
HOW TO PREVENT BEING USED TO
INCREASE MARKET SHARE, AND
AGAIN, YOU KNOW, KIND OF
IMPLEMENTED IN THIS
PATIENT-CENTERED APPROACH.
AND HOW CAN MANAGEMENT BE
COLLABORATIVE?
AND THEN ANOTHER OUTSTANDING
QUESTION WAS, THE GROUP WAS IN
AGREEMENT THAT MOBILE STROKE
UNITS SHOULD NOT BE LAUNCHED AS
A STRATEGY TO INCREASE MARKET
SHARE BY TAKING PATIENTS AWAY
FROM A CLOSER MORE APPROPRIATE
FACILITY AND THAT DISPOSITION
SHOULD BE REGULATED BY THE STATE
SUCH AS A COMMUNICATION CENTER.
NEXT, ALL STATES SHOULD HAVE
PROTOCOLS WHICH MAY BE
REGIONALIZED DIRECTING PATIENTS
TO THE CLOSEST APPROPRIATE
FACILITY.
FROM THE TIME OF SYMPTOM
DETECTION AND LVO SCREENING.
AND YOU KNOW, JUST A POINT TO
TALK ABOUT FOR LVO SCREENING IS,
THERE IS A LOT OF VARIABILITY IN
TERMS OF THE UTILIZATION OF
THESE PRE-HOSPITAL SCALES.
AS MARK CAN ATTEST TO, IN OUR
STATE OF CONNECTICUT, WE DO NOT
HAVE A FORMAL LVO SCREENING
SCALE STATEWIDE THAT IS
PERFORMED WITHOUT READY AND EL
IJ DECISIONS BEING DONE.
SO THERE IS VARIABILITY IN THIS.
AGAIN, I MENTIONED THE AHA
INITIATIVE, THE ASLS COURSE THAT
IS THE INNOVATION OF MIAMI.
THERE'S ALSO A POTENTIAL --
POTENTIALLY AHA-FUNDED TARGET
STROKE SURVEY THAT WILL BE
COMING OUT TO STROKE CENTERS
WITHIN THE NEXT FEW YEARS FROM
ONE OF THE SCIENTIFIC
SUBCOMMITTEES BY WHICH CENTERS
ARE SURVEYED AS TO WHY THEY ARE
NOT DOING PREHOSPITAL LVO
SCREENING IN THEIR REGION, SO AS
TO IDENTIFY THE OBSTACLES, THE
BARRIERS AND THE DIVERSE
OPINIONS THAT EXIST IN DIFFERENT
REGIONS FOR THIS QUESTION.
AND FINALLY, IS IT REASONABLE TO
BELIEVE THAT WE COULD AGREE ON
AN LVO SCREENING TOOL TO
FACILITATE STANDARDIZED
EDUCATION.
IN THE ABSENCE OF THIS,
TELESTROKE IN THE PRE-HOSPITAL
SETTING IS ANEAR WAY TO BRING
THE NEUROLOGIST IN THE BACK OF
THE AMBULANCE TO HELP MAKE THESE
ASSESSMENTS.
WE CAN GO TO THE NEXT SLIDE.
AND THEN FINALLY IN THIS DOMAIN,
THE BEST PRACTICES OR SOLUTIONS
FOR CONSIDERATION WERE, ONE,
PRE-HOSPITAL REIMBURSEMENT AS WE
HAD TALKED TO AND TYING TO THE
COMPLEXITY OF CARE AND NOT
PUTTING IT ON THE PATIENT.
NUMBER TWO, LINKAGE TO THE
PRE-HOSPITAL DATA AS WELL IS
SOMETHING THAT WAS TALKED ABOUT.
THERE ARE MANY COMPLICATING
FACTORS THAT ARE INVOLVED IN
THIS.
AS MANY OF YOU MAY EXPERIENCE IN
YOUR SYSTEM, SOMETIMES IT'S JUST
A CHALLENGE TO GET THE
PRE-HOSPITAL DATA ON AN
INDIVIDUAL PATIENT IN YOUR
SYSTEM, BUT CERTAINLY THERE IS
IMPORTANT INFORMATION TO COME
FROM EMS, INCLUDING BUT NOT
LIMITED TO THE PATIENT'S CONTACT
INFORMATION, THE PHONE NUMBER OF
LOVED ONES WHO MAY NEED TO BE
CONTACTED FOR THE LAST KNOWN
NORMAL TIME.
SO THIS IS A CRITICAL TRANSFER
OF INFORMATION.
AND THEN PRE-HOSPITAL EDUCATION
AS WELL, AS WE HAD TALKED ABOUT
THE TRAINING, THE CERTIFICATE
PROGRAMS AND OTHER THINGS THAT
WILL JUST COMPLEMENT AND ENHANCE
OUR CURRENT SYSTEMS AS THEY
EXIST.
NEXT I'M GOING TO HAND OVER THE
OTHER TWO THEME AREAS TO
COMMANDER ODOM TO DISCUSS.
>> THANK YOU SO MUCH.
HI, EVERYONE.
SO NEXT SLIDE, PLEASE.
I'M GOING TO GO AHEAD AND GET
STARTED ON THE ECONOMIC
SELF-CARE RESOURCE AND THE
DEMOGRAPHIC SECTION.
SO NEXT SLIDE, PLEASE.
WE DIDN'T HAVE ANY INFORMATION
TO CORRECT IN THE ECONOMIC
SECTION.
NEXT SLIDE.
SO SOME OUTSTANDING QUESTIONS OR
GAPS THAT WERE CONSIDERED AMONG
THE GROUP, AND I JUST WANT TO
HIGHLIGHT, IT WAS A GREAT
CONVERSATION IN BOTH THESE
GROUPS YESTERDAY, SO THANK YOU
SO MUCH FOR YOUR INPUT.
FOR ECONOMICS AND HEALTHCARE
RESOURCES, THE GROUP SUGGESTED
THAT THERE BE A STANDARDIZATION
AROUND REIMBURSEMENT FOR
PROCEDURES AND CURRENTLY THERE'S
A LOW REIMBURSEMENT RATE.
WHETHER IT BE IN THE
PRE-HOSPITAL SETTING OR
IN-HOSPITAL SETTING, SO THAT'S
SOME GAPS THAT NEED TO BE
CONSIDERED.
THERE'S A NEED FOR A NATIONAL
STROKE REGISTRY AS MENTIONED
PREVIOUSLY TO HAVE CONSISTENT
DATA TO IDENTIFY DISPARITIES
CONSISTENTLY ACROSS THE UNITED
STATES AND REGIONS.
AND IN ADDITION, THERE IS A NEED
TO UNDERSTAND THE UTILITY OF
TELESTROKE AND TELEMEDICINE AT
THE DISPATCH, AS WELL AS
PROVIDING, ONCE DISCHARGED IN
TERMS OF PROVIDING EDUCATION TO
PATIENTS.
NEXT SLIDE, PLEASE.
SO SOME NEW BEST PRACTICES OR
SOLUTIONS TO CONSIDER FOR THE
ECONOMICS AND HEALTHCARE
RESOURCES SECTION IS TO CONSIDER
SUPPORTING COMMUNITY EDUCATORS
WHO ARE TRUSTED MEMBERS OF THE
COMMUNITY, WHICH MAY INCLUDE
NURSES, PHARMACISTS, COMMUNITY
HEALTH WORKERS.
IN ADDITION, A SUGGESTION WAS TO
TEST IMPLEMENTATION OF VARIOUS
EDUCATIONAL TOOLS AND
METHODOLOGIES THROUGH
DISSEMINATION AND IMPLEMENTATION
RESEARCH, SO GETTING SOME OF
THESE IDEAS AND QUESTIONS AND
PUTTING THEM TO SCIENTIFIC
RIGOROUS -- SCIENTIFICALLY
RIGOROUS TESTING, WHETHER IT BE
THROUGH QUALITATIVE OR
QUANTITATIVE RESEARCH.
IN ADDITION, IDENTIFYING
BARRIERS TO USE OF 911, WHICH
MAY INCLUDE MISTRUST OF LOCAL
AUTHORITIES, IMPACT OF RACE AND
RACIAL TENSIONS IN SOCIETY, A
PRIVATE VERSUS PUBLIC MATTER,
AND AFFORDABILITY OF DIALING
911.
SO WHAT IS THE COST TO THE
PATIENTS WHO CHOOSE TO USE 911.
AND THEN, AGAIN, THIS IDEA OF AN
INCENTIVIZING INDIVIDUALS WHO GO
INTO THE EMS PROFESSION OR EVEN
THE STROKE/NEUROLOGIST
PROFESSION TO INCREASE
DIVERSITY.
NEXT SLIDE, PLEASE.
SO THE NEXT SECTION WAS THE
DEMOGRAPHICS SESSION.
NEXT SLIDE.
AND WE DIDN'T HAVE ANY NEW
CONTENT OR CORRECTION OF
INFORMATION BROUGHT UP.
NEXT SLIDE.
SO SOME OUTSTANDING GAPS TO
CONSIDER WITHIN THE DEMOGRAPHICS
SECTION WAS TO IDENTIFY WAYS TO
FURTHER ENHANCE 911 UTILIZATION
THROUGH COMMUNITY
EDUCATION/ENGAGEMENT WITH
DIVERSE COMMUNITIES.
SO AGAIN, IDENTIFYING THOSE --
WE WOULD NEED DATA TO IDENTIFY
WHICH COMMUNITIES NEED WHAT
INFORMATION AND WHO ARE THE
TRUSTED RESOURCES AND HOLDERS OF
THAT INFORMATION.
BEING ABLE TO BUILD TRUST AND
BREAK DOWN BARRIERS BY DOING
THINGS FOR RATHER THAN TO A
PARTICULAR COMMUNITY, AND
IDENTIFYING, AGAIN, THOSE
COMMUNITY CHAMPIONS.
NEXT, THERE WAS THE SUGGESTION
TO REMOVE ARTIFICIAL BARRIERS
AND CROSSING STATE LINES WITHOUT
INSURANCE PENALTY, SO DOING
WHAT'S BEST FOR THE PATIENT, NOT
JUST BASED ON SOME ARBITRARY
LINE GOING TO THE RIGHT HOSPITAL
FOR THAT PATIENT.
IDENTIFYING STRATEGIES REGARDING
PRE-HOSPITAL DISPATCH AND MOBILE
STROKE UNIT UTILIZATION TO
DECREASE DISPARITIES, AND REDUCE
GEOGRAPHICAL DISPARITIES IN
TRAVEL TIME WITH SPECIAL
ATTENTION TO RURAL AND SPECIFIC
DEMOGRAPHIC COMMUNITIES, IE,
NATIVE AMERICANS.
AUGMENTATION OF STROKE SYSTEM
INTERACTION WITH NON-HE ENGLISH
SPEAKING POPULATIONS SHOULD BE A
PRIORITY, AND THEN FOR EMS
AGENCIES WITH BANDWIDTH,
LEVERAGING THEIR RESOURCES TO
PERFORM COMMUNITY EDUCATION IN
THE HOME OR COMMUNITY SETTING.
NEXT, THERE WAS THE SUGGESTION
TO CAPITALIZE UPON NOVEL SYSTEM
INNOVATIONS FOR OTHER PATIENT
POPULATIONS, AND EXPLORING THE
FEASIBILITY OF APPLICATION OF
THOSE INTERVENTIONS FOR STROKE
POPULATIONS, AND THE SUGGESTION
THERE WAS TELE-911.
SO BEING ABLE TO IDENTIFY THE
STROKE WITH DISPATCH.
NEXT SLIDE, PLEASE.
SO SOME NEW BEST PRACTICES OR
SOLUTIONS TO CONSIDER WITHIN
THIS GROUP CAME UP, THE
UTILIZATION OF MULTIPLE
COMPONENTS OF THE STROKE SYSTEM
OF CARE TO PERFORM COMMUNITY
ENGAGEMENT AND EDUCATION, SO NOT
JUST FROM A NEUROLOGIST BUT ALL
OF THE HOSPITAL STAFF,
ESPECIALLY THOSE WELL EDUCATED
ON STROKE, LIKE NURSES, EMS
STAFF, EMERGENCY MEDICAL TEAMS,
AND STROKE TEAMS.
CONSIDER THE IDENTIFICATION AND
UTILIZATION OF COMMUNITY
CHAMPIONS.
AGAIN, FOLKS IN THE CHURCHES OR
COMMUNITIES WHO CAN BE EDUCATED
ABOUT STROKE AND BE THOSE FOLKS
THAT REACH OUT TO OTHERS TO
SHARE INFORMATION AND COMPLEMENT
THE INFORMATION THAT A PATIENT
OR FAMILY MEMBER MIGHT RECEIVE
WITHIN THE HOSPITAL SETTING.
THE TRANSLATION OF KEY STROKE
EDUCATIONAL RECOURSES INTO THE
MOST PREVALENT LANGUAGES SPOKEN
IN THE COMMUNITY.
AGAIN, IDENTIFYING THOSE AREAS
OR POCKETS WITHIN A COMMUNITY
THAT MAY NEED SUPPORT OUTSIDE OF
ENGLISH-SPEAKING, FAST EDUCATION
OR BE FAST IN TRANSLATING THOSE
SO MESSAGES TO THE LANGUAGE THAT
IS PARTICULAR FOR THAT
COMMUNITY.
FURTHER INCORPORATION OF
CULTURAL AND DEMOGRAPHIC
COMPETENCY TRAINING INTO ANNUAL
ONGOING EMS EDUCATION AND EMS
PRE-CERTIFICATION PROGRAMS.
AGAIN, EMS PROVIDERS ARE OFTEN
THOSE FIRST PROVIDERS SEEN IN
THE COMMUNITY SO HAVING CULTURAL
COMPETENCE PARTICULARLY FOR A
SPECIFIC COMMUNITY MIGHT BE
HELPFUL IN GAINING THAT TRUST.
AND THEN FURTHER BUILD UPON
CURRENT NIH INITIATIVES WITH THE
SPECIFIC FOCUS ON STROKE,
PERFORMING RESEARCH INTO
DISPARITIES AND STROKE CARE,
EDUCATION, ACCESS TO THE SYSTEM,
WHERE LGBTQ POPULATIONS AND WITH
THE AIMS OF UNDERSTANDING THE
UNIQUE BARRIERS AND CHALLENGES
FOR ACCESS AND TERRITORIMENT. TREATMENT.
I BELIEVE THAT IS OUR LAST
SLIDE?
YES.
SO THANK YOU SO MUCH.
FOR YOUR ATTENTION TO OUR
PRE-HOSPITAL SESSION.
DO WE HAVE ANY QUESTIONS OR DO
WE NEED TO MOVE ON TO THE NEXT?
>> THANK YOU SO MUCH, DR. ODOM
AND DR. WIRA, FOR THAT EXCELLENT
PRESENTATION.
LET ME JUST ASK A FEW QUESTIONS
HERE, AND THEN WE'LL MOVE ON.
SOMETHING THAT DR. WIRA AND I
ARE WELL AWARE OF IN THE GREAT
STATE OF CONNECTICUT, BUT I
SUSPECT THIS IS A NATIONAL
PROBLEM, IS THE FRAGMENTATION OF
EMS.
I MEAN, IN OUR STATE HERE IN
CONNECTICUT, WHICH IS NOT A
LARGE STATE TO BE FRANK WITH
YOU, WE HAVE DOZENS OF EMS
COMPANIES, AND THERE'S NO BIG
REGULATORY PERSON OR ENTITY THAT
SORT OF HAS OVERSIGHT OF THEM.
AND I SUSPECT IN MANY OTHER
PARTS OF THE COUNTRY AND STATES,
THEY ALSO -- IT'S SOMEWHAT OF AN
EMS FREE-FOR-ALL.
SOME STATES LIKE TEXAS HAVE A
LITTLE BIT MORE CENTRAL
CONTROLLING AUTHORITY, BUT IT'S
THIS FRAGMENTATION OF EMS THAT
REALLY CONCERNS ME, BECAUSE NO
MATTER WHAT WE DEVELOP HERE IN A
TASK FORCE, THE DIFFERENT EMS
COMPANIES AND AGENCIES ARE
BASICALLY GOING TO DO WHAT THEY
WANT, UNLESS WE COME UP WITH A
BETTER SOLUTION.
SO I JUST WANTED TO OPEN THIS UP
TO COMMANDER ODOM, DR. WIRA AND
OTHERS, IF THIS PROBLEM THAT I'M
TRYING TO EXPLAIN IS REALLY
NATIONWIDE, AND IF SO, WHAT ARE
SOME POTENTIAL SOLUTIONS?
BECAUSE OTHERWISE, AT THE END OF
THE DAY, IT'S SORT OF LIKE
TRYING TO HERD CATS, AND THAT
DOESN'T GO VERY WELL.
>> I WANT TO MAKE A COMMENT.
THANK YOU FOR BRINGING THAT --
IT'S RAFAEL.
THANK YOU FOR BRINGING THAT ON.
BECAUSE WE HAVE THE SAME PROBLEM
HERE IN PUERTO RICO, AND THE
THING IS THAT SOMETIMES THE
HOSPITAL ADMINISTRATORS HAVE
DEALS WITH THE EMS PEOPLE, SO
THEY TAKE THE PATIENTS TO THEIR
HOSPITAL INSTEAD, NO MATTER HOW
FAR THEY ARE FROM THE HOSPITAL.
SO THAT IS A BIG PROBLEM, AND
THAT HARMS THE PATIENT, BECAUSE
SOMETIMES IF YOU'RE HAVING A
STROKE THAT OCCURRED NEAR MY
HOSPITAL, WHY YOU ARE GOING TO
TAKE THE PATIENT 45 MINUTES AWAY
FROM OUR HOSPITAL TO GET
TREATMENT?
THAT'S THE SAME DISCUSSION WE
HAD YESTERDAY IN TERMS OF THE
U.S. -- ISLAND, THAT THEY FLY
THE PATIENTS TO MIAMI INSTEAD OF
BRINGING HERE TO PUERTO RICO.
I THINK THAT THAT IS SOMETHING
THAT HAS TO BE REGULATED.
I THINK THAT MAYBE THE POLICIES
AND REGULATIONS SECTION THAT
THEY HAVE TO ADDRESS THAT AND
MAYBE -- I THINK THE BEST WAY IS
TO STANDARDIZE.
POLICING SOME REGULATIONS ABOUT
ALL OF THIS, BUT THIS IS
SOMETHING THAT IS HAPPENING.
I THINK THAT IT'S NATIONWIDE.
WHEN I WAS DOING THE FELLOWSHIP,
THE SAME THING HAPPENED.
SO IT'S NOTHING NEW, YOU KNOW,
THE SAME THING HAPPENED NOT ONLY
WITH STROKE, THEY HAPPEN WITH
OTHER NEUROSURGICAL CONDITIONS.
TRAUMA, HEMORRHAGE.
EMS PEOPLE ALREADY HAVE A
CONTRACT OR THEY HAVE BIAS WITH
CERTAIN HOSPITALS TO BRING
PATIENTS TO THEIR E.R.
SO THAT IS A -- IT'S A REAL
THING HAPPENING.
>> THANK YOU FOR SHARING THOSE
CONCERNS AND EXAMPLES.
YES, OTHER COMMENTS.
SHERITA.
>> I THINK ONE THING WE CAN DO
IS WE CAN LOOK AT THE STATES
THAT DO IT WELL.
LIKE THA HAWAII DOES HAVE A
CENTRALIZED EMS SYSTEM AND IT IS
A LOT EASIER TO GET THINGS DONE
AND IMPLEMENTED ACROSS THEIR
WHOLE STATE, WHICH IS AMAZING
BECAUSE THEY HAVE THE DIFFERENT
ISLANDS AND THEY STILL ARE ABLE
TO HAVE A CENTRALIZED EMS
SYSTEM.
SO I WOULD SAY THE FIRST STEP
WOULD PROBABLY BE TO LOOK AT THE
STATES THAT ARE DOING IT AND
DOING IT WELL.
>> THAT'S A GREAT POINT THAT YOU
BRING UP, MARK, AND GREAT POINTS
BY THE OTHERS AS WELL.
YOU KNOW, WE SAID YESTERDAY THAT
THERE'S NO TWO STROKES THAT ARE
THE SAME.
YOU CAN SAY THE SAME ABOUT EMS.
THERE'S NO TWO EMS SYSTEMS THAT
ARE IDENTICAL AS WELL.
AND EMS SYSTEMS, THEY CAN HAVE
THEIR STRENGTHS, THEIR
WEAKNESSES, THEIR BARRIERS,
THEIR OBSTACLES AND CAN HAVE
RESOURCE ISSUES AND JUST --
THERE'S SUCH A WIDESPREAD
DIVERSITY IN TERMS OF HOW SOME
OF THEM MAY FUNCTION.
TAKING A STEP BACK, ONE WAY THAT
NATIONAL ADVOCACY
ORGANIZATIONS -- AND THIS
CERTAINLY HAS BEEN DONE IN SOME
REGIONAL AREAS FOR STROKE AND
ALSO FOR OTHER DISEASE ENTITIES,
IS TO JUST MAKE RECOMMENDATIONS
THAT THEN CAN BE BUILT UPON,
BECAUSE SOMETIMES A
RECOMMENDATION FROM AN ADVOCACY
ORGANIZATION MAY NOT TRANSLATE
IMMEDIATELY TO THE APPROPRIATE
CORRESPONDING OEMS
RECOMMENDATIONS FOR A STATE OR
LEGISLATIVE CHANGES, BUT THEY
CAN CERTAINLY GIVE GOOD
AMMUNITION FOR MOVING THE NEEDLE
FORWARD.
POTENTIALLY A RENEWED AND
FURTHER FOCUS ON KEY EMS STROKE
PERFORMANCE METRICS.
YOU KNOW, SOME REGIONS TALK
ABOUT 911 TO DISPATCH TIME,
DISPATCH TIME TO SITE ARRIVAL
TIME.
ONSET OF STROKE TO EMS TRANSFER
TIME.
ONSET OF STROKE TO STROKE CENTER
ARRIVAL TIME.
SO POTENTIALLY THERE COULD MAYBE
BE SOME GUIDANCE FROM
ORGANIZATIONS LIKE THE BRAIN
DETECT COALITION AND AHA AND
OTHER COALITIONS FOR
PRE-HOSPITAL METRICS, AND THEN
INDIVIDUAL SYSTEMS REGARDLESS OF
HOW THEY'RE STRIVING TO
FUNCTION, AT LEAST HAVE GOALS TO
TRY TO ATTAIN AND ACHIEVE.
>> AS I WAS GOING TO SAY THE
SAME SORT OF TOPICS, IDENTIFYING
WHAT BASIC DATA METRICS ARE
REQUIRED ACROSS EMS SYSTEMS IN
TERMS OF COLLECTION AND
IDENTIFYING RECOMMENDATIONS LIKE
STRONG RECOMMENDATIONS AROUND
QUALITY METRICS FOR STROKE
VICTIMS, INSTITUTING THAT AT
SOME SORT OF REGIONAL OR STATE
LEVEL TO TRY TO GET CLARITY
ACROSS THE AGENCIES.
>> THANK YOU ALL FOR THIS GREAT
DISCUSSION.
I KNOW THAT FOR THINGS LIKE
TRAUMA, THERE'S REGULATORY AND
STATE RULES AND REGULATIONS THAT
EMS HAS TO TAKE CERTAIN FIEPS OF TYPES OF
PATIENTS TO LEVEL 1 TRAUMA
CENTERS, FOR EXAMPLE.
I KNOW ANOTHER EXAMPLE IS TEXAS,
EMS HAS TO TAKE STROKE PATIENTS
TO THE NEAREST CERTIFIED STROKE
CENTER.
AND THESE CASES GET TRACKED.
SO THE FINANCIAL INCENTIVES THAT
THE GENTLEMAN FROM PUERTO RICO
WAS TALKING ABOUT, THAT WOULDN'T
HAPPEN IN TEXAS VERY OFTEN
BECAUSE THEY COLLECT THAT DATA
AND IF THEY END UP SHUNTING
PATIENTS TO HOSPITALS THAT THEY
MAY HAVE SOME FINANCIAL
CONNECTION WITH THAT ARE NOT
CERTIFIED STROKE CENTERS, THEY
WOULD GET REPORTED UP TO THE
GOVERNOR'S OFFICE WHO TRACKS
THAT, AND THERE WOULD BE
REPERCUSSIONS.
SO THAT WOULD NOT BE AN ONGOING
ISSUE.
>> SO THEY HAVE POLICIES AND
REGULATIONS REGARDING THAT?
>> CORRECT.
THEY DO.
AND IN THE STATE OF TEXAS, YOU
CAN BE CERTIFIED BY THE JOINT
COMMISSION AS A -- IT'S A
TWO-STEP PROCESS.
YOU HAVE TO BE CERTIFIED AS A
STROKE CENTER BY SOME
INDEPENDENT ORGANIZATION, SUCH
AS THE JOINT COMMISSION, BUT
THEN THE STATE DESIGNATES YOU AS
A STROKE CENTER.
IT'S A TWO-STEP PROCESS.
AND ONLY AFTER THE STATE
DESIGNATION ARE THEN YOU IN A
POSITION TO SEE ACUTE STROKE
PATIENTS.
SO IT'S A TWO-STEP.
CERTIFIED BY AN INDEPENDENT
BODY, RECOGNIZED BY THE STATE,
AND THEN YOU GET PUT ON THIS
LIST THAT EMS CAN TAKE STROKE
PATIENTS TO YOU.
AND YOU REALLY CAN'T BYPASS IT
OR YOU CAN'T DO IT VERY MUCH,
OTHERWISE YOU ARE CALLED TO
ACCOUNT FOR THAT.
BUT AGAIN, THAT'S TEXAS.
IT'S NOT LIKE THAT IN OTHER
STATES.
OKAY.
THIS IS A GREAT DISCUSSION.
WE'RE CAPTURING THESE POINTS.
>> MARK, THERE IS A HAND RAISED
BY CHRISTOPHER RICHARDS.
>> THANKS, EVERYONE.
THIS IS OF COURSE A VERY
INTERESTING CONVERSATION.
WE MIGHT ALSO WANT TO THINK
ABOUT LOOKING AT THE
PRE-HOSPITAL APPROACH TO CARDIAC
ARREST AS A MODEL AS WELL.
SO IN A LOT OF RESPECTS, WE KIND
OF SEE OUR EMS SYSTEMS, THEIR
APPROACH TO OUT OF HOSPITAL
CARDIAC ARREST MANAGEMENT AS A
MARKER FOR HOW WELL YOU DO
EVERYTHING ELSE.
AND IT'S BEEN A REALLY GREAT WAY
TO IMPROVE THE OVERALL CARE OF
CARDIAC ARREST PATIENTS IN THE
PRE-HOSPITAL SETTING THAT'S
REALLY TRANSLATED TO OTHER KEY
TYPES OF CONDITIONS.
SO MAYBE EVEN THROUGH KIND OF
MESSAGING AND COLLABORATION THAT
WE HAVE WITH OUR EMS PARTNERS,
USING APPROACH TO ACUTE STROKE
BE THAT FROM DISPATCH,
RECOGNITION THROUGH
ON-SCENE SCREENING THROUGH THE
EFFICIENCY OF CARE PROVIDED AS
SEEN AS A MARKER FOR ACUTE CARE
I THINK WOULD GO A LONG WAY HERE
AS WELL.
NOW THAT'S ALL PREDICATED ON
THINGS LIKE DR. WIRA AND
DR. ODOM YOU WERE MENTIONING AS
WELL, WHICH IS TYING QUALITY
METRICS, TYING REIMBURSEMENT TO
THE COMPLEXITY OF CARE THAT'S
PROVIDED, BECAUSE THAT'S REALLY
REFLECTIVE OF KIND OF MOVING
FORWARD.
SOMETIMES THERE'S THE TOP-DOWN
APPROACH THAT CAN WORK, BUT
SOMETIMES IT CAN REALLY ALIENATE
OUR EMS PARTNERS SO WE HAVE TO
BE MINDFUL OF THAT AND REALLY
KIND OF FRAME THE OVERALL CARE
ON SCENE AS A MARKER OF, BOY,
THIS IS REALLY HIGH QUALITY,
EFFICIENT CARE THROUGH THIS
VARIETY OF DIFFERENT METHODS.
>> EXCELLENT.
THANK YOU ALL.
ANY OTHER QUESTIONS OR COMMENTS
BEFORE WE GO ON TO THE NEXT TASK
FORCE REPORT?
IF NOT, THEN LET'S MOVE ON.
WHO IS NEXT IN THE QUEUE FOR THE
TASK FORCE?
IS THAT LEE FOR HYPERACUTE
THERAPY?
>> I THINK SO.
>> OKAY.
CAN SOMEBODY BRING UP
DR. JENSEN'S SLIDES?
>> SO WHILE WE'RE BRINGING THE
SLIDES UP, I JUST WANT TO SAY,
WE HAD NO CORRECTIONS ACROSS OUR
SECTIONS.
UNFORTUNATELY, DR. HASSAN HAS A
FAMILY ISSUE THAT HE HAS TO DEAL
WITH SO I WILL BE PRESENTING
ALSO THE INFORMATION FROM THE
TWO SESSIONS THAT HE COVERED.
ONE THING, THANK YOU VERY MUCH,
DR. WIRA, DR. ODOM, FOR YOUR
PRESENTATION.
A LOT OF WHAT YOU SAID ACTUALLY
BLED INTO -- WE BLED INTO YOUR
PRE-HOSPITAL CARE, SOME OF THE
THINGS I'M GOING TO TALK ABOUT
ALSO BLEED INTO INPATIENT CARE.
AND INTERESTINGLY, A LOT OF THE
CONVERSATION HAD TO DO WITH THE
EPOCH WE DIDN'T INCLUDE, WHICH
IS THE POST-HOSPITAL CARE.
SO IF YOU COULD GO TO THE NEXT
SLIDE, PLEASE.
SO THERE ARE OVERARCHING THEMES
AMONG OUR FOUR CROSS-CUTTING
THEMES.
AND AGAIN, SOME OF THESE ARE NOT
NECESSARILY JUST RELATED TO THE
HYPERACUTE OR ACUTE SITUATION IN
THE EMERGENCY DEPARTMENT.
BUT ACROSS ALL THREE EPOCHS.
AND IT CAME UP IN ALL OF THE
BREAKOUT SESSIONS.
ONE WAS THE COMMUNITY ENGAGEMENT
THAT'S REQUIRED FOR US TO GET
THE WORD OUT ABOUT STROKE
EDUCATION, AND HOW THERE'S
DEFINITELY A NEED TO PROMOTE
TRUST IN NOT ONLY EMS BUT OTHER
HEALTHCARE PROVIDERS WITH THE
COMMUNITY.
SO WE REALLY DO NEED TO WORK ON
THAT SO THAT WHEN THEY COME TO
THE HYPERACUTE PHASE, THEY ARE
COMFORTABLE WITH MOVING ON
THROUGH THE TREATMENT PHASE.
ALSO, ANOTHER OVERARCHING THEME
WAS JUST THE UTILIZATION OF ALL
HEALTHCARE PROVIDERS, INTERESTED
PARTIES, SO SO MUCH IN THE E.D.
IS FOCUSED ON CARE PROVIDED BY
THE PHYSICIANS AND OBVIOUSLY ONE
OF THE ISSUES THAT CAME UP WAS
THE NEED FOR MORE STROKE
TRAINING FOR E.D. PHYSICIANS,
BUT THE OTHER BIG CONVERSATION
WAS AROUND USING ALL OF OUR
HEALTHCARE PROVIDERS,
IDENTIFYING STROKE PATIENTS AND
GETTING THEM THROUGH THIS SYSTEM
INTO EITHER THE ANGIO EXECUTE OR
GETTING ITPA OR WHATEVER THEIR
TREATMENT IS GOING TO BE, BY
UTILIZING EVERYBODY THAT COMES
IN CONTACT WITH THAT PATIENT.
SO THAT INCLUDES THE NURSES THAT
SEE THE PATIENTS AND THEY GET
INTWHEN THEY GETINTO TRIAGE, UTILIZING NPs
APAANDPAs TO DO THE INITIAL
EVALUATION AND STROKE SCORE.
UTILIZING YOUR PHARMACISTS AS
PART OF YOUR TEAM.
THEY'RE USUALLY PART OF THE TEAM
ALREADY IF YOU'RE GETTING IVTPA,
BUT WHERE ELSE CAN THEY BE
UTILIZED IN DELIVERY OF CARE?
AND THEN OF COURSE WE MOVED ON
TO HOW CAN WE INCORPORATE
RESIDENTS AND OTHER INDIVIDUALS
SUCH AS HIGH SCHOOL STUDENTS AT
SOME POINT IN TIME.
OBVIOUSLY THE HIGH SCHOOL
STUDENTS OUTSIDE OF THIS
PARTICULAR EPOCH.
ALSO, MAXIMIZING THE USE OF
TECHNOLOGY.
CLEARLY THERE ARE A LOT OF
ISSUES AROUND ACCESS TO
TELENEUROLOGY, BUT THERE'S ALSO
OTHER TELEHEALTH TECHNOLOGY
ISSUES.
ONE OF THEM THAT WE RUN INTO IS
ACCESS TO NEURORADIOLOGISTS TO
HELP INTERPRET THE ADVANCED
IMAGE, PARTICULARLY THE CT
PERFUSION.
THERE WERE A LOT OF RADIOLOGISTS
THAT WORK AT THESE INDIVIDUAL
HOSPITALS THAT ARE NOT
COMFORTABLE WITH THAT, SO OFTEN
YOU NEED MORE SUBSPECIALTY
RADIOLOGY CARE OUTSIDE OF THE
TELENEUROLOGIST.
AND THIN TH THEN THE IDEA OF
REPURPOSINGS CATH LABS TO
PROVIDE ON-SITE THRO THROMBECTOMY
CARE AT CERTAIN HOSPITALS WHICH
GOES TO OUR OUT OF BOX THINKING
LINE THERE, WHICH IS THE USE OF
A MOBILE INTERVENTIONAL STROKE
TEAM TO GET THE PATIENT --
INSTEAD OF GETTING THE PATIENT
TO THE INTERVENTIONAL TEAM
HAVING THE INTERVENTIONAL TEAM
ACTUALLY GOING TO THE PATIENT.
OBVIOUSLY THAT'S GOING TO
REQUIRE USE OF AN ANGIO SUITE
AND THE MOST COMMON ONES ARE
CARDIAC CATH LABS.
ALSO THINKING -- FORWARD
THINKING AS WE MOVE ON INTO THE
FUTURE IS THE USE OF ROBOTIC AND
INSTRUMENTATION, WHICH IS
CURRENTLY BEING USED IN SOME
PLACES FOR CARDIAC PROCEDURES,
WHERE ACTUALLY THE
INTERVENTIONALIST DOES NOT NEED
TO GO TO THE SITE BUT CAN
ACTUALLY PERFORM THE PROCEDURE
USING ROBOTIC INSTRUMENTATION.
SO THAT'S COMING, SOMETHING WE
SHOULD THINK ABOUT AND PERHAPS
START TO INVESTIGATE EARLY.
AND THEN OF COURSE RESEARCH
OPPORTUNITIES.
SO IF WE COULD GO TO THE NEXT
SLIDE, PLEASE.
SO IN TERMS OF THE GEOGRAPHY
SUBGROUP, I'M GOING TO LOOK AT
THIS AS WHAT THE CONVERSATION
WAS AROUND AND WHAT INDIVIDUALS
IN THE SUBGROUP DISCUSSED AS
POSSIBLE FIXES FOR THE VARIOUS
ISSUES.
SO ONE OF THE MAJOR ISSUES WAS
ACCESS TO STROKE EXPERTISE OR
HIGHER LEVEL OF CARE, SUCH AS A
PSC HOSPITALS SENDING PATIENTS
UP TO TSCs, ONE GAP, HOW TO
GET THE PATIENT TO THE CLOSEST
STROKE HOSPITAL IF THEY NEED
THAT HIGHER LEVEL OF CARE, AND
IS THERE A WAY WE CAN USE
ARTIFICIAL INTELLIGENCE TO
DETERMINE WHERE THAT CLOSEST
AVAILABLE HOSPITAL IS,
REGARDLESS OF WHETHER OR NOT
IT'S IN THE SAME HEALTHCARE
SYSTEM.
IN OTHER WORDS, YOU USE
GEOGRAPHY AS OPPOSED TO THESE
ARTIFICIAL HEALTH SYSTEMS LIKE
YOU HAVE TO GO TO THE MOTHER
SHIP, WELL, THAT SHOULDN'T HAVE
TO -- THAT SHOULDN'T INTERFERE
WITH TRANSPORTING A PATIENT TO
THE CLOSEST STROKE HOSPITAL.
ALONG THOSE LINES, SINCE
PARTICULARLY IN THE SMALLER
STATES, THERE'S OVERLAPPING
HEALTH SYSTEMS THAT CROSS STATE
LINES, THERE NEEDS TO BE A
MECHANISM FOR ALLOWING EMS
SYSTEMS TO TAKE PATIENTS ACROSS
STATE LINES TO RECEIVE THAT
FASTER CARE.
CLEARLY THERE'S A NEED FOR MORE
STROKE TRAINING FOR E.D.
PHYSICIANS AND THE THOUGHT IS
PROVIDING MORE EDUCATION IN
THEIR RESIDENCIES.
ALSO HAVING CONTINUING MEDICAL
EDUCATION FOR THE E.D. --
ALREADY PRACTICING E.D.
PHYSICIANS, AND ENCOURAGE STROKE
TRAINING OR ROTATION THROUGH
NEUROLOGY FOR BOTH PEOPLE
WANTING TO GO INTO EMERGENCY
MEDICINE BUT EVEN AT THE MEDICAL
SCHOOL LEVEL.
AND TO ENCOURAGE AND GROW
PHYSICIAN EXTENDERS,
PARTICULARLY ALONG THE LINES OF
P.A. AND/OR N.P. STROKE TEENS TEAMS
THAT CAN HELP TO IDENTIFY THESE
PATIENTS FASTER.
ALSO STROKE TRAINING FOR FIRST
RESPONDERS, YOU KNOW, BOTH EMS
AND IN THE E.D. PROPER SUCH AS
THE NURSES AND TECHS THAT OFTEN
ARE THE FIRST PEOPLE TO SEE
PATIENTS.
THE AVAILABILITY OF ADVANCED
IMAGING IN FACILITIES THAT SEE
STROKE PATIENTS.
IT'S REALLY IMPORTANT NOT ONLY
TO HAVE THE ABILITY TO DO C.T.
BUT ALSO CTA AND C.T. PER FUCHS.
AGAINPERFUSION.HAVING A TRAINED RADIOLOGIS T
THAT CAN ACTUALLY DETERMINE THAT INTERPRET THAT
IMAGING PROPERLY.
CROSS-CUTTING THEMES TALKING
ABOUT LOAN REPAYMENT PLANS FOR
PHYSICIANS WHO ARE IN J1 OR H-1B
PROGRAMS, TO IMPROVE ACCESS TO
CARE IN GEOGRAPHICALLY REMOTE OR
UNDERSERVED AREAS.
NEXT, PLEASE.
THE NEXT THOUGHT WAS IN TERMS OF
RESEARCH, WE NEED TO MOVE
MONSIGNOR TOWARDS
DISSEMINATION/IMPLEMENTATION
SCIENCE FUNDING OPPORTUNITIES,
AND ALSO FUNDING FOR -- AGAIN,
THIS IS OUTSIDE OF SORT OF OUR
EPOCH BUT IT CAME UP, FOR RURAL
COORDINATORS AND SUBACUTE TO
CHRONIC CARE COORDINATORS IN
ORDER TO PROMOTE RESEARCH IN THE
UNDERSERVED AND RURAL PATIENT
POPULATIONS.
SO YOU NEED PEOPLE TO
PARTICIPATE IN RESEARCH AND
TRYING TO GET THEM INVOLVED IN
THAT AT THE HYPERACUTE/ACUTE
LEVEL IS PROBLEMATIC, SO THE
IDEA IS TO ACTUALLY FUND PEOPLE
WHO CAN GO OUT INTO THE
COMMUNITY, PROMOTE RESEARCH, AND
THAT'S VIRGINIA BEACH AND NOT
EXPERIMENTATION SO THAAND -- BEING COMFORT ABLE BEING
INVOLVED IN RESEARCH.
AND MORE OPPORTUNITIES IN
RESEARCH, MARK, I THINK YOU
BROUGHT UP YESTERDAY HOW OFTEN
THOSE SORT OF PROPOSALS GET
SCORED LOW, AND SO THEY DON'T
GET FUNDED, AND THAT NEEDS TO --
WE NEED TO SEE THAT AS A GAP AND
FIGURE OUT A WAY THAT THERE'S
MORE OBVIOUS FUNDING FOR THOSE
SORT OF RESEARCH PROJECTS.
ONE OF THE EXAMPLES THAT CAME UP
WAS THE ALTEPLASE USAGE
DISPARITIES, AND TESTING A PRE
AND POST -- PROVIDING A SCRIPT
TYPE OF SCENARIO.
THE NEXT ISSUE WAS TELEMEDICINE,
AND GR GRAND FROM THE V.A. GAVE
A VERY NICE SORT OF OVERVIEW OF
LESSONS THAT WE COULD TAKE FROM
THE V.A. MODEL, SUCH AS LICENSE
TELENEUROLOGISTS FROM ANY STATE
OR TERRITORY SO THEY CAN -- YOU
CAN USE THEM ACROSS STATE LINES.
RECRUIT NEUROLOGISTS FOR A
NATIONAL TELESTROKE PROGRAM, AND
THE USE OF ADVANCED PRACTICE
NURSES AS PHYSICIAN EXTENDERS
EVEN IN TELEMEDICINE.
THE POLICY AND REGULATIONS
SUBGROUP TALKED ABOUT IN TERMS
OF SYSTEMS OF CARE, POLICIES TO
PROMOTE STROKE SYSTEMS OF CARE
WWITHIN STATES AND REGIONS, A LA
THE REGIONAL COMMAND CENTERS IN
STROKENET, TO UTILIZE THE
COMPREHENSIVE STROKE CENTERS AS
HUBS FOR ACUTE STROKE PROTOCOLS
AND STROKE EDUCATION, SO
ACTUALLY MAKE IT THEIR
RESPONSIBILITY TO PROVIDE THOSE
SORT OF SERVICES TO THOSE FOLKS.
HAVE GEE GRFICALLY SENSIBLE
THROMBECTOMY TRIAGE, WORKING
THROUGH THAT WHOLE COMPETITIVE
MARKET AND MEDICAL SYSTEM SILOS
SO THAT WE BREAK DOWN THOSE
BARRIERS.
CONNECT STATE AND REGIONAL EMS
GOVERNANCE TO STROKE SYSTEMS OF
CARE SO YOU'RE TALKING THE SAME
LANGUAGE AND WORKING TOGETHER.
THAT MAY REQUIRE LEGISLATION AT
THE STATE LEVEL OR THE TERRITORY
LEVEL.
ALLOCATE STANDARDS AND RESOURCES
FROM INTERFACILITY TRANSPORT
FROM CRITICAL ACCESS HOSPITALS
TO STROKE CENTERS SO THAT THERE
ARE ACTUALLY STANDARDS OF CARE
ACROSS STATE AND REGIONS.
NEXT, PLEASE.
THIS IS FROM OUR TELEMEDICINE
EXPERTS.
DR. SUTHERLAND, I DON'T THINK
HE'S ON THE CALL TODAY, BUT HE
REALLY IS A LEADER IN THIS, AND
WE LOOK TO HIM FOR TALKING ABOUT
TELEMEDICINE.
SO ONE IS TO EXPAND LICENSURE TO
PERFORM TELESTROKE SERVICES
ACROSS STATE LINES AND REQUIRE
CONNECTIVITY FROM OUT OF STATE
PROVIDERS TO LOCAL PROVIDERS
AND/OR NETWORKS.
TO ALLOW UNIVERSAL CREDENTIALING
FROM HUB TO SPOKE AND MAINTAIN
ELIMINATION OF ORIGINATING SITE
RESTRICTIONS FOR TELESTROKE
SERVICES.
TO CONTINUE OR EXPAND
TELEMEDICINE COVERAGE USING THE
COVID-19 EMERGENCY AUTHORIZATION
ACT, AND PROMOTE POLICIES THAT
SUPPORT ACCESS TO HIGH QUALITY
BROADBAND FOR RURAL AND CRITICAL
ACCESS SETTINGS, INCLUDING
STROKE CARE.
AND WORK WITH ACGME TO ENSURE
THE INCLUSION OF TELESTROKE AND
TELEMEDICINE TRAINING.
NEXT, PLEASE.
AND RESEARCH.
AGAIN, EVERYBODY HAD SOME GREAT
RESEARCH IDEAS, SO FOR EXAMPLE,
NINDS REQUEST FOR APPLICATIONS
FOCUSED ON DISPARITIES AND ACUTE
TROAK TREATMENSTROKE TRIAGE AND INCLUDE
TELESTROKE AS A COMPONENT OF
ACUTE STROKE CLINICAL TRIALS
WITHIN STROKENET.
NEXT, PLEASE.
THE DEMOGRAPHIC SUBGROUP FOCUSED
A LOT ON RESEARCH AND EDUCATION,
AND I THINK DR. WIRA AND
DR. ODOM TALKED ABOUT THIS.
INVESTIGATE THE REASONS FOR
DISPARITY IN TPA USE IN AFRICAN
AMERICANS AND THE BARRIERS TO
CALLING 911, WHICH THEY
OUTLINED.
GET INTO HIGH LEVEL RESEARCH
THAT MOVES BEYOND ASSOCIATION,
REALLY GETS INTO CAUSATION.
REQUIRE MORE STROKE EDUCATION IN
MEDICAL SCHOOL AND RESIDENCY
TRAINING AND SHOULD MAYBE BE
MANDATED, THAT YOU GET STROKE
TRAINING OR DO A KNEWOLOGY NEUROLOGY
ROTATION AND ALSO STROKE
AWARENESS TRAINING FOR
NON-TRADITIONAL GROUPS.
A COUPLE EXAMPLES WERE THE
YOUNGER PATIENT POPULATION SUCH
AS THE MIND YOUR RISK FOR YOUNG
AFRICAN AMERICAN MEN OR
EDUCATION AT THE GRADE SCHOOL
LEVEL, SUCH AS KIDS HEART
CHALLENGE.
I REALIZE THIS IS, AGAIN,
OUTSIDE OF OUR EPOCH.
THIS IS WHAT CAME UP IN THE
BREAKOUT GROUPS.
AND ALSO LOOKING AT COMMUNITY
RESOURCES.
SO COULD MEDICAL STUDENTS
PERHAPS TAKE OWNERSHIP OF --
MEDICAL SCHOOLS TAKE OWNERSHIP
OF COMMUNITY EDUCATION IN
REGIONS WHERE THERE IS A MEDICAL
SCHOOL.
HEALTH SYSTEM CERTIFICATION
REQUIRING MORE THAN TOKEN
COMMUNITY INVOLVEMENT.
SO YOU HAVE TO ACTUALLY HAVE,
FOR EXAMPLE, A FOCUSED PROGRAM,
YOU CAN'T JUST GIVE A HEALTH
FAIR AND SAY, HEY, WE'VE MET OUR
CRITERIA.
FIND COMMUNITY CHAMPIONS AND PUT
THEM ON STROKE COMMITTEES.
AND MAKE CMS REIMBURSEMENT
DEPENDENT ON COMMUNITY
INVOLVEMENT.
NEXT, PLEASE.
THEN AGAIN BACK TO TECHNOLOGY,
HOW CAN WE HELP SMALLER AND
RURAL PSCs ACQUIRE TECHNOLOGY
THAT'S REQUIRED IN ORDER TO
PROVIDE STROKE CARE.
NETWORK SOFTWARE AND TELESTROKE
SERVICES, HOW DO THEY GET
REIMBURSED FOR THAT, CAN THERE
BE FUNDING FOR THAT?
SAME WITH IMAGING TECHNOLOGY.
HOW DO WE HELP LOPTS THA HOSPITALS THAT
NEED HIGHER LEVELS OF IMAGING
GET THAT, AND HOW DO WE NAVIGATE
THE KICKBACK LAWS THAT PREVENT
NETWORKS FROM GIFTING SOFTWARE
TO THEIR SMALLER HOSPITALS.
NEXT, PLEASE.
THE ECONOMICS SUBGROUP BREAKOUT
FOCUSED ON COSTS AND PERSONNEL,
SO MANY OF THE -- MUCH OF THEIR
FOCUS WAS ON THE TERRITORIES
LIKE PUERTO RICO, VIRGIN
ISLANDS, AND THE NATIVE AMERICAN
RESERVATIONS.
OBVIOUSLY THE GAP IS THE NEED
FOR ROW BEST TELESTROKE
SERVICES.
WHAT FUND SOMETHING THERE TO
SUPPORT THE TELESTROKE SERVICES
FOR THESE UNDERSERVED AREAS, AND
CAN WE GET STROKE COMMAND
CENTERS TO HELP MOVE PATIENTS TO
APPROPRIATE LOCATIONS FOR THE
STROKE CARE WITHIN THEIR
REGIONS.
THE NEED TO ATTRACT AND RETAIN
PERSONNEL OFTEN DO NOT WANT TO
WORK NECESSARILY IN REMOTE
AREAS.
SO AGAIN, THE MEDICAL STUDENTS
CAME UP IN PUERTO RICO WITH
THEIR MEDICAL SCHOOL TO STAY IN
THEIR COMMUNITY.
THE NEED FOR EQUITABLE MEDICARE
REIMBURSEMENT NEEDS TO BE
EVALUATED.
IN PUERTO RICO, THEY GET 40%
LESS THAN THE STATES AND THAT IS
UNFAIR AND INEQUITABLE.
AND THE NEED FOR BETTER
REIMBURSEMENT MODELS.
THE FACT THAT SMALLER HOSPITALS
CANNOT AFFORD THE INFRASTRUCTURE
AND THEY CANNOT BECOME A HIGHER
LEVEL OF CARE WITHOUT THE
REIMBURSEMENT NECESSARY FOR THE
INFRASTRUCTURE.
I THINK THAT'S MY LATION SLIGHT.
>LAST SLIDE.
>> THANK YOU VERY MUCH, LEE.
A LOT OF DIFFERENT ASPECTS OF
CARE.
SOMETHING THAT I WANTED TO JUST
BRING UP FOR CONSIDERATION, AND
YOU DO THIS ON A DAILY BASIS,
MANY OF US DO NOD, BUT I DO
REMEMBER YEARS AGO, THERE WAS A
LOT OF RESISTANCE TO I.V. TPA
THERAPY BECAUSE OF THE COST.
LIKE THE COST EXCEEDED THE
ENTIRE DRG FOR STROKE.
AND I WAS WONDERING IF YOU WERE
FACING THE SAME PUSHBACK FOR
ENDO VASCULAR THERAPY, IF THE
DRG -- AND YOU KNOW, WHAT CMS
DID IS THEY RAISED THE DRG, THE
REIMBURSEMENT FOR THE DRG FOR
TPA, THEY ACTUALLY CREATED A NEW
ONE SO THAT THE HOSPITALS COULD
GIVE TPA WITHOUT FEAR IT WOULD
CHEW UP ALL OF THE DRG.
IS THE SAME DYNAMIC WORKING FOR
ACUTE ENDO VASCULAR THERAPY, OR
IS IT MORE IMBALANCE OR ARE
THERE OPPORTUNITIES HERE TO
REMOVE BARRIERS?
>> WELL, THAT'S A GREAT
QUESTION, AND I HAVE TO SAY, I
HAVE WORKED IN FOUR DIFFERENT
HEALTHCARE SYSTEMS, NOW ALL IN
THE STATE OF VIRGINIA, BUT I
HAVE WORKED IN FOUR, AND THERE
HAS NEVER BEEN ANY PUSHBACK FROM
THE HOSPITAL.
NONE.
ABOUT WHETHER OR NOT WE'RE DOING
TOO MANY THRO THROMBECTOMIES OR
THEY'RE LOSING MONEY.
AND I THINK IT'S BECAUSE THE
REIMBURSEMENT IS SIGNIFICANT.
I HAVE TO SAY, THE PLACE WHERE
IT SEEMS TO BE MORE LIKELY WHERE
THE HOSPITAL MAY FIND LESS
PROFITABLE IS THE LENGTH OF STAY
IN TERMS OF GETTING PATIENTS OUT
TO REHAB.
SO THAT SEEMS TO BE, YOU KNOW,
IF ANYBODY HAS A
REIMBURSEMENTISH YOU'LL OR
HOSPITAL FINANCIAL ISSUE, IT'S
BECAUSE THESE PATIENTS MAY
LINGER LONGER IN THE HOSPITAL
THAN THEY REALLY NEED TO.
SO NO, THAT'S NOT COME UP, AT
LEAST NOT IN MY WORLD.
>> I WANT TO MAKE A COMMENT
BECAUSE I WORK WITH MANY
ADMINISTRATION IN DOING THIS.
THE GOOD THING FOR THE
ADMINISTRATION IS THAT WHEN YOU
DO A THROBBING BECK TO THROMBECTOMY, YOU D O A
DIAGNOSTIC ANGIOGRAM TOO.
SO -- THEY PAY WELL, EVEN
MEDICARE.
BUT THAT COMPENSATES THE LOSS OF
MONEY THAT THEY GET FROM THE
THROMBECTOMY, BECAUSE
THROMBECTOMY, MEDICARE DOESN'T
PAY TOO MUCH.
AS WELL AS TPA.
SO IT'S PROFITABLE TO THE
HOSPITAL BECAUSE THE DIAGNOSTIC
ANGIOGRAM AND OTHER REQUIREMENTS
THAT YOU HAVE, BEFORE YOU DO THE
THROMBECTOMY, THEY PAY GOOD TO
THE HOSPITAL, AND THEY
COMPENSATE.
I THINK THAT THAT'S WHY WE DON'T
SEE TOO MUCH DIFFERENT.
BUT THERE IS A BIG DIFFERENCE
BETWEEN TPA AND THE VASCULAR
TREATMENT.
>> YEAH, THERE ARE CARVEOUTS,
BUT THE DRG IS HIGHER FOR
THROMBECTOMY TOO.
>> YES.
>> JUSTIN OR KEVIN, DO YOU HAVE
ANYTHING YOU WANT TO ADD TO
THAT?
>> I WOULD AGREE WITH YOU, I'VE
NOT REALLY SEEN A PROBLEM WITH
THAT.
BUT I THINK IT MAY BE COMING, WE
SEE THE DEVICE COMPANIES ARE
MAKING MORE AND MORE EXPENSIVE
DEVICES AND PUSHING FOR MORE
EXPENSIVE DEVICES BEING USED SO
THAT'S EVENTUALLY GOING TO START
EATING AWAY AT THE DRG,
SOMETHING WE HAVE TO BE AWARE.
I WAS A LITTLE BIT SURPRISED
ABOUT THE EMPHASIS ON
INTERPRETATION OF IMAGING.
BECAUSE I THINK WE'VE AT LEAST
SEEN MANY HOSPITALS WHERE YOU
HAVE SORT OF A READ AND TREAT
POLICY FOR YOUR STROKE
NEUROLOGISTS, AND SO PERHAPS WE
WOULD MAYBE NEED TO EMPHASIZE
MORE THE EDUCATION OF OUR STROKE
NEUROLOGISTS AND OUR
ENDOVASCULAR SPECIALISTS BEING
ABLE TO INTERPRET THE IMAGING
AND MAKE DECISION ON THE IMAGING
AND NOT RELY ON A DIAGNOSTIC
NEURORADIOLOGIST TO DO THAT.
THAT WOULD KIND OF ELIMINATE
PART OF THAT PROBLEM.
>> THAT'S A GREAT POINT, I HAVE
TO SAY, LIVING IN THE WORLD OF
ACADEMIC MEDICINE, WE JUST READ
OUR OWN STUDIES AND THAT'S IT,
WE'RE DONE.
BUT HAVING WORKED IN THREE
NON-ACADEMIC BUT COMPREHENSIVE
STROKE CENTERS, YOU'LL FIND
THEY'RE SOMETIMES -- OBVIOUSLY
IF YOU'RE THE PERSON ON CALL AND
HAVING SOMETHING LIKE VIS AI
ALLOWING YOU TO SEE WHAT'S GOING
ON --
>> BEING ABLE TO LEVERAGE THAT
A.I. TECHNOLOGY AS WELL TO MAKE
THE INTERPRETATION.
>> MAY I TELL YOU SOMETHING, ONE
OF THE THINGS -- I WAS THE
PIONEER HERE IN PUERTO RICO, ONE
OF THE THINGS THAT I NEGOTIATED
WITH THE MEDICAL INSURANCE WAS
THAT I DO THE INTERPRETATION OF
MY WORK.
SO I GET PAID FOR THE
INTERPRETATION ON MY WORK, NOT
THE RADIOLOGIST.
SO I THINK THAT THERE IS, IN
TERMS OF WHAT YOU NEGOTIATE WITH
THE MEDICAL INSURANCE MORE THAN
POLICY.
THAT'S HAPPENED TO ME.
SO EACH THROMBECTOMY OR ANY
ENDOVASCULAR CASE THAT I DO, I
ALSO GET PAID FOR THE
INTERPRETATION TOO.
>> I THINK THAT'S COMMON.
I THINK WHAT WE'RE TALKING ABOUT
IS THE NONINVASIVE IMAGING,
WHERE YOU'RE INTERPRETING THE
CTP OR THE CTA.
>> OH, WELL, THAT'S --
>> WHETHER YOU GET PAID OR NOT I
DON'T THINK IS AS IMPORTANT
BECAUSE YOU'RE COVERED IN THE
DRG, BUT BEING ABLE TO MAKE
INTERPRETATION AND NOT WAITING
FOR A NEURORADIOLOGIST
NECESSARILY OR EVEN IN THE
COMMUNITY, MANY PEOPLE
INTERPRETING ARE NOT TRAINED
NEURORADIOLOGISTS, THEY'RE
GENERAL RADIOLOGISTS.
>> JUSTIN?
>> MY UNDERSTANDING IN THE
THROMBECTOMY CODE 61645, THAT'S
BUNDLED WITH ANY DIAGNOSTIC
STUDIES YOU DO FOR THAT VESSEL.
SO UNLESS YOU'RE DOING OTHER
VESSELS OF A DSA FOR SOME OTHER
REASON, WHICH OFTEN IS NOT THE
CASE, RIGHT, WE JUST PULL THE
CLOT OUT AND WE'RE DONE, I DON'T
KNOW THAT WE CAN RELY ON DSA TO
MAKE UP OTHER COSTS.
I THINK IN MOST CASES WE'RE NOT
DOING FULL ANGIOS ON THESE
PATIENTS.
>> CORRECT.
I AGREE.
SOMEBODY HAD A HAND UP.
>> I DON'T SEE ANYBODY ELSE WITH
A HAND UP.
>> IT JUST WENT DOWN.
>> YEP.
ALL RIGHT.
EXCELLENT.
THANK YOU VERY MUCH, LEE AND
OTHERS.
THIS WAS A VERY ROBUST
DISCUSSION.
I THINK WE CAPTURED SOME OF THE
KEY POINTS.
I THINK NEXT WE'RE GOING TO MOVE
ON TO THE INPATIENT CARE
DISCUSSION, AND I DON'T KNOW
WHETHER KAREN OR LARRY OR BOTH
ARE GOING TO BE DOING THAT?
>> THINK WE'RE GOING TO TAG TEAM
A LITTLE BIT BUT I'M GOING TO
START IT OFF.
IF YOU COULD GO TO THE NEXT
SLIDE.
SO I WITHOUT I WOULD START WITH
SOME GENERAWITH -- I THOUGHT I WOULD START
WITH GENERAL THOUGHTS THAT CAME
UP WITH THE DISCUSSION OF
INPATIENT CARE AND DISPARITIES
THROUGHOUT THE WHOLE SESSION
YESTERDAY.
INCLUDING SOME OF THE THEMES
HERE THAT CROSSED A LOT OF THE
SUBGROUPS, THE CROSS-CUTTING
THEMES, BREAKOUT SESSIONS AS
WELL.
SO FIRST OF ALL, I WOULD COMMENT
THAT DESPITE VERY EXTENSIVE
RESEARCH INTO THE LITERATURE
AND -- OUR OVERALL FINDING WAS
THERE WAS SURPRISINGLY LITTLE
KNOWN ABOUT DISPARITIES IN
INPATIENT CARE, AND I'M NOT SURE
WHY THAT IS, BUT IT HASN'T BEEN
REALLY AS WELL STUDIED AS OTHER
ASPECTS THAT WE'RE TALKING ABOUT
TODAY.
THE INFORMATION WE DID FIND
PRIMARILY HAD TO DO WITH
ANTI-PLATELET AGENTS,
ANTICOAGULANTS AND STATINS, BUT
THERE WAS VERY LITTLE WE COULD
FIND ON DIAGNOSTIC TESTING AND
PROCEDURES, AND I THINK SOME OF
THE DISCUSSION YESTERDAY CENTER
ON WHAT WE COULD DO ABOUT THAT
AND HOW WE COULD USE INFORMATION
THAT'S ALREADY OUT THERE, SUCH
AS WHAT'S AVAILABLE IN THE
ELECTRONIC RECORD, BIG DATABASES
SUCH AS THE GET WITH THE
GUIDELINES DATABASE, WHERE THERE
ARE OPPORTUNITIES FOR PERHAPS
MINING DATA WITH REGARD TO
DISPARITIES IN INPATIENT CARE
THAT WE HAVEN'T REALLY LOOKED
AT, AND THERE PROBABLY ARE
SIGNIFICANT BARRIERS TO THAT,
BUT PROBABLY DESERVES FURTHER
ATTENTION AS TO HOW WE CAN GET
AT SOME OF THESE ISSUES THROUGH
SOME OF THE EXISTING DATA THAT
IS UNIQUELY AVAILABLE FOR
INPATIENT CARE.
THERE WAS THE DISCUSSION OF
TRYING TO MOVE FROM ASSOCIATION
TO CAUSATION, WHICH I THINK
WE'RE ALL IN FAVOR.
WE NEED TO GET TO THE BOTTOM OF
NOT JUST WHAT THOSE DISPARITIES
ARE, BUT WHY THEY ARE.
AS OTHERS HAVE MENTIONED
ALREADY, THIS ISSUE OF
POST-ACUTE CARE AND REHAB IS AN
IMPORTANT ONE.
WE KIND OF INTEGRATED INTO THIS
INPATIENT CARE, AND I THINK LEE
MENTIONED THAT HER GROUP ALSO
TALKED SOME ABOUT THAT, BUT THIS
IS AN IMPORTANT AREA AND MAYBE
GOING FORWARD SHOULD BE A
SEPARATE AREA OF STUDY.
THE DISCONNECTION BETWEEN WHAT
GOES ON IN THE HOSPITAL AND
POST-HOSPITAL CARE IS, I THINK,
AN AREA THAT IS PROBLEMATIC AND
PROBABLY CONTRIBUTES TO
DISPARITIES.
AND SO TO THE EXTENT THAT WE CAN
INTEGRATE THOSE THINGS AND
PROBABLY WITH PRE-HOSPITAL CARE
AS WELL, INTO A COHERENT SYSTEM
WOULD CERTAINLY HELP THIS
SITUATION.
ONE OTHER THING THAT WAS
MENTIONED WAS TRYING TO ADDRESS
THESE SOCIAL FACTORS FOR
PATIENTS BEFORE DISCHARGE RATHER
THAN TRYING TO DEAL WITH THEM
AFTERWARDS WOULD BE A
CONTRIBUTION AND, I BELIEVE, I
THINK IT WAS MEDSTAR THAT
MENTIONED THEY'RE ALREADY DOING
THIS, AND I THINK THAT'S A GREAT
SUGGESTION.
MARK, YOU MENTIONED THE IDEA OF
MAYBE ALLOWING SHORTER INPATIENT
REHAB STAYS TO REDUCE COSTS AND
THAT WOULD BE A POSSIBILITY AS
WELL.
SOME OF THE THINGS THAT CROSSED
OUR BREAKOUT SESSIONS IN TERMS
OF THEMES, TELEMEDICINE SEEMS TO
AB THEME THAT CROSSES EVERYTHING
HERE AND CERTAINLY OUR INPATIENT
CARE AREA WAS NO EXCEPTION.
PARTICULARLY WITH REGARD TO
REHABILITATION THERAPY
POST-ACUTE CARE, WHERE THERE ARE
CLEAR DISPARITIES IN TERMS OF
THE UTILIZATION OF INPATIENT
REHAB VERSUS HOME HEALTH VERSUS
SNFs AND THE ABILITY TO
DELIVERY HA REHAB IN THE HOME
THROUGH TELEMEDICINE, WHICH IS
POSSIBLE AND THERE ARE ALREADY
RANDOMIZED CONTROL TRIALS SHOW
THAT THIS IS JUST AS EFFECTIVE
AS IN-PERSON REHAB WOULD
CERTAINLY BE A CONTRIBUTION.
FINALLY, WE TALKED A LOT ABOUT
THE FACT THAT IN REVIEWING THE
LITERATURE, THERE WERE LOTS OF
DIFFERENT DEFINITIONS AND THERE
WAS DIFFERENT TERMINOLOGY USED
IN DIFFERENT STUDIES AND
DIFFERENT WAYS, AND TO THE
EXTENT THAT WE COULD STANDARDIZE
THINGS, IT WOULD REALLY HELP US
NOT ONLY BRINGING TOGETHER SOME
OF THE PREVIOUS LITERATURE BUT
GOING FORWARD, AS PEOPLE
CONTINUE TO STUDY THIS, AND I'M
SURE THAT WILL OCCUR, THAT WE'RE
ALL TALKING ABOUT THE SAME
THINGS AND WE CAN PULL THINGS
TOGETHER BY THIS KIND OF
STANDARDIZATION.
SO NOW I'LL TURN IT OVER TO
KAREN FOR DISCUSSION OF THE
INDIVIDUAL BREAKOUT ROOMS.
>> THANKS, LARRY.
THAT WAS A TREMENDOUS OVERVIEW.
LET ME JUST TALK ABOUT THE
INDIVIDUAL BREAKOUT SESSIONS.
THE FIRST WAS FOCUSED ON
DEMOGRAPHICS.
AND IT'S VERY CLEAR THAT IT
IMPOSSIBLE TO SEPARATE
DEMOGRAPHICS FROM OTHER FACTORS
LIKE GEOGRAPHY OR SOCIOECONOMIC
STATUS.
AND SO IT'S IMPORTANT MOVING
FORWARD TO TRY AND LOOK AT
MULTIPLE ELEMENTS AND TEASE OUT
THE ACTUAL CAUSAL FACTORS THAT
ARE CONTRIBUTING TO INEQUITIES.
OVERALL, THERE SEEM TO BE A
CONSISTENT PATTERN THAT RURAL
AREAS WERE DISADVANTAGED, THAT
HAD TO DO WITH LESS
INFRASTRUCTURE, FEWER
PHYSICIANS, FEWER ACTUAL
INSTITUTIONS TO DELIVER CARE.
A COMMENT WAS MADE THAT THERE IS
NO REHAB HOSPITAL IN THE STATE
OF NORTH DAKOTA, SO OBVIOUSLY IT
WOULD BE VERY CHALLENGING FOR
PATIENTS IN THAT REGION TO
ACTUALLY GET ACUTE INPATIENT
REHABILITATION.
RURAL AREAS MAY NOT HAVE THE
TECHNOLOGY OR THE CONNECTIONS
THAT THAT SILL TATE
TELEMEDICINE.
AS LARRY MENTIONED, PROVISION OF
TELESERVICES IS ONE WAY TO GET
EXPERTISE INTO REMOTE
COMMUNITIES.
POST-ACUTE CARE WAS VERY
CONSISTENTLY IDENTIFIED AS AN
AREA THAT REQUIRES GREATER
RESEARCH.
THE TRANSITION OF CARE, THE
SELECTION OF THE POST-ACUTE CARE
SETTING MAY INVOLVE INEQUITIES
BASED ON INSURANCE ACCESS, AND
THERE ARE NO STANDARDS FOR
INDIVIDUALS ACTUALLY MEETING THE
BAR FOR INPATIENT ACUTE
REHABILITATION THAT ARE
CONSISTENT ACROSS THE COUNTRY
AND ACROSS SYSTEMS.
INTERVENTIONS ARE TEAM-BASED AND
MULTIFACTORIAL, AND TO THE
EXTENT THAT THOSE TEAMS EXIST
AND ARE POPULATED BY A DIVERSE
WORKFORCE, THERE MAY BE
IMPROVEMENTS IN DELIVERING CARE
TO PEOPLE -- RACE, ETHNIC AND
AGE CATEGORIES.
STANDARDIZATION OF CARE ENABLES
INDIVIDUALS TO ELIMINATE BIAS.
SO PHYSICIANS WHO FOLLOW
ALGORITHMS OR PROTOCOLS STILL
HAVE THE ABILITY TO MODIFY CARE
FOR THE INDIVIDUAL, BUT FOR THE
MOST PART, IT ALLOWS OBJECTIVE
EVALUATION OF WHETHER THERE'S
CONSISTENT APPLICATION OF
DIAGNOSTIC AND THERAPEUTIC
ALGORITHMS.
IN TERMS OF ECONOMICS, AGAIN, WE
FOUND GREATEST EVIDENCE OF
DISPARITIES IN POST-ACUTE CARE.
THE PROVISION OF INPATIENT
REHABILITATION VERSUS HOME
HEALTH VERSUS SKILLED NURSING
FACILITIES DID VARY BY AGE, SEX,
AND RACIAL GROUPS.
IT'S UNCLEAR TO WHAT EXTENT
THESE DIFFERENCES IMPACT
RECOVERY, MORTALITY, AND
SECONDARY STROKE PREVENTION
INTERVENTIONS LIKE IMPLANTABLE
LOOP MONITORS FOR ATRIAL
FIBRILLATION.
IT IMPORTANT TO NOTE THAT THE
SOCIAL DETERMINANTS OF HEALTH
ENCOMPASS NOT ONLY FAMILY
INCOME, BUT ALSO THE FAMILIAR
DYNAMICS AND INSURANCE, AND ALL
OF THESE IMPACT THE DYNAMIC OF
THE ACUTE INPATIENT
HOSPITALIZATION AND DELIVERY OF
POST-ACUTE CARE.
THERE'S VERY LITTLE DATA
AVAILABLE IN THIS AREA, AND WE
FELT THAT THERE NEEDED TO BE
HYPOTHESIS-DRIVEN RESEARCH TO
ASSESS INTERVENTIONS AND ADDRESS
SOME OF THESE IMPORTANT ISSUES.
POLICY AND REGULATIONS.
WE LOOK TO SEE WHETHER THERE
MIGHT BE OPPORTUNITIES FOR
EVALUATING AND ACCREDITING
AGENCIES SUCH AS THE JOINT
COMMISSION TO EVALUATE
DISPARITIES AND INCORPORATE IT
INTO THE CERTIFICATION PROCESS.
MANY OF THESE DATA ARE READILY
AVAILABLE THROUGH ELECTRONIC
MEDICAL RECORDS, BUT INCLUDING
THIS IN THE CERTIFICATION
PROCESS WOULD ALLOW
IDENTIFICATION OF DISPARITY AND
PERHAPS IDENTIFY AREAS FOR
FUTURE RESEARCH.
THERE'S AN EXTENSIVE LITERATURE
THAT INDICATES THAT THE USE OF A
HOSPITAL STLOAK UNI STROKE UNIT IMPROVES
CARE AND OUTCOMES, BUT THIS HAS
NOT BEEN EVALUATED IN THE
CONTEXT OF A SPOKE AND HUB
MODEL.
APPLICATION OF COMMON ORDER SETS
AND EVIDENCE-BASED PATHWAYS CAN
STANDARDIZE CARE ACROSS
DIFFERENT RURAL AND COMMUNITY
HOSPITALS.
TELEHEALTH CAN SUPPORT NOT ONLY
EMERGENCY DEPARTMENT CARE, BUT
ALSO HELP STANDARDIZE AND
OPTIMIZE MANAGEMENT DURING THE
INPATIENT HOSPITALIZATION.
COST AND REIMBURSEMENT
LIMITATIONS DO CREATE
DISPARITIES IN RURAL AND REMOTE
AREAS.
AND THIS SHOULD BE EVALUATED AND
PERHAPS ADDRESSED BY MORE FORMAL
STATE AND FEDERAL POLICIES.
IN TERMS OF GEOGRAPHY, AGAIN,
THERE'S AN EMESHMENT, THERE'S AN
IMPEDIMENT TO UNDERSTANDING
CONTRIBUTORS TO DELIVERIES AND
INEQUITIES OF CARE.
ACROSS THE UNITED STATES, THERE
ARE CERTAINLY AREAS THAT ARE
ENRICHED WITH NEUROLOGICAL AND
IN PARTICULAR STROKE EXPERTISE,
BUT OTHER AREAS WHERE THIS MIGHT
NOT BE AVAILABLE FOR AN ENTIRE
REGION.
TELESTROKE IS ONE WAY TO HELP
ADDRESS THIS.
SECONDARY STROKE PREVENTION IS
OBVIOUSLY CRITICAL TO LONG-TERM
OUTCOMES TO HELP PREVENT
RECURRENT STROKE AND VASCULAR
COGNITIVE IMPAIRMENT.
BUT IT'S UNCLEAR TO WHAT EXTENT
TRANSITIONS OF CARE AND
CONTINUED SUPPORT OF SECONDARY
STROKE PREVENTION ARE AVAILABLE
IN THE COMMUNITY.
DEVELOPING PATIENT
SELF-MANAGEMENT TOOLS MAY HELP
EMPOWER PATIENTS AND STANDARDIZE
THIS PRACTICE ACROSS THE UNITED
STATES.
AND THEN FINALLY A VERY
CONSISTENT THEME WAS THE LACK OF
AVAILABILITY OF INPATIENT REHAB
BY REGION, AND PATIENTS MAY NOT
BE WILLING TO BE HOURS AWAY FROM
THEIR FAMILIES AND MAY CHOOSE
NOT TO GO FOR INPATIENT
REHABILITATION CARE AS A RESULT.
SO THERE ARE MANY OUTSTANDING
QUESTIONS AND GAPS.
ADDITIONAL RESEARCH IS NEEDED TO
ACTUALLY EXPLORE DISPARITIES IN
MODERN UTILIZATION OF IMAGE IMAGING
AND PROCEDURES.
I WANT TO THANK GLEN FOR
FORWARDING ME A MANUSCRIPT FROM
2003 THAT WAS PUBLISHED IN
STROKE.
IT CAME UP IN THE DISCUSSION
YESTERDAY THAT THE V.A. SYSTEM
PROVIDES A VERY NICE CAPACITY
FOR EVALUATING THE APPLICATION
OF BOTH TESTING AND PROCEDURES,
AND LARRY GOLDSTEIN WAS THE
FIRST AUTHOR ON THE MANUSCRIPT
THAT LOOKED AT THIS
RETROSPECTIVELY.
ALTHOUGH IT COVERED MANY OF THE
AREAS THAT ARE OF INTEREST EVEN
TODAY, SUCH AS USE OF C.T., CTA,
MRI, CAROTID ULTRASOUND AND
PROCEDURES SUCH AS CAROTID
ENDARTERECTOMY.
THE DATA USED IN THAT STUDY WAS
FROM 1995 TO 1997, SO QUITE
DATED AT THIS POINT IN TIME, AND
IT ONLY INVOLVED DATA FROM THE
VA SYSTEM, WHICH INTRODUCES SOME
BIAS.
SO READDRESSING THIS IN A MORE
COMPREHENSIVE MANNER IN 2022 AND
MOVING FORWARD WILL BE VERY
IMPORTANT TO UNDERSTAND WHETHER
INEQUITIES EXIST.
WE NEED TO FURTHER EXPLORE THE
INTERACTIONS BETWEEN THE VARIOUS
FACTORS CONTRIBUTING TO
DISPARITIES, GEOGRAPHY,
SOCIOECONOMIC STATUS, AND
DEMOGRAPHICS NEED TO BE BETTER
TEASED OUT.
TELEMEDICINE WAS A CONSISTENT
POTENTIAL SOLUTION FOR
SUPPORTING CARE ACROSS MANY
DIFFERENT EPOCHS OF STROKE CARE,
AND IT HAS REALLY BEEN
UNDEREVALUATED IN THE
IN-HOSPITAL STROKE SETTING.
AND THEN FINALLY, COST AND
REIMBURSEMENT ISSUES ASSOCIATED
WITH INPATIENT AND POST
DISCHARGE COMPLIANCE NEEDS TO BE
BETTER DEFINED.
FLAWCIAL THANK YOU, AND I'LL
TURN THITHANK YOU, AND I'LL TURN THISBACK OVER TO LARRY.
>> THANKS, KAREN.
SO WE PUT TOGETHER SOME KIND OF
OVERREACHING SUGGESTIONS FOR
BEST PRACTICES AND SOLUTIONS
BASED UPON THE BREAKOUT SESSIONS
AND THE GENERAL DISCUSSIONS OF
THE INPATIENT TASK FORCE, AND
THEY'RE LISTED HERE.
SO FIRST, THIS CONCEPT OF
STANDARDIZATION OF PRACTICES
ACROSS HOSPITALS, NOT TO TRY TO
TAKE AWAY ANYONE'S INDEPENDENCE
OR ABILITY TO PERSONALIZED CARE,
BUT AT LEAST TO CREATE PATHWAYS
THAT ARE CONSISTENT AND GIVE
GUIDANCE TO PEOPLE AT HOSPITALS
THAT DON'T HAVE STROKE CENTERS
AND STROKE EXPERTISE, AND TO DO
THAT, THERE ARE SIMPLE WAYS THAT
THAT CAN BE ACCOMPLISHED BY
SHARING ORDER SETS AND PATHWAYS
AND PROVIDING TELEMEDICINE
SUPPORT.
LEE JENSEN ALSO MENTIONED FROM
HER GROUP THE IDEA OF THE HUB
AND SPOKE MODEL AND HOW THAT
COULD REDUCE DISPARITIES, AND I
THINK THAT OFTENTIMES WE HAVE
THE TELEMEDICINE COMPONENT OF A
HUB AND SPOKE NETWORK KIND OF
STOP AFTER THE EMERGENCY ROOM,
UPON ADMISSION TO THE HOSPITAL.
BUT THERE'S NO REASON WHY WE
CAN'T CONTINUE IT THROUGHOUT THE
INPATIENT STAY AS WELL AS IN THE
POST HOSPITAL SEGMENT TO HELP IN
THOSE SITUATIONS AS WELL.
BRINGING THE STROKE EXPERTISE TO
THE HOSPITAL FOR THINGS EVEN
BEYOND THE ACUTE DECISION-MAKING
IN THE EMERGENCY ROOM.
WE TALKED ABOUT THE FOCUS ON
CAUSATION RATHER THAN
ASSOCIATION.
I THINK THAT'S AN IMPORTANT STEP
WE NEED TO TAKE, EXACTLY HOW TO
DO THAT IS POSSIBLY A MORE
DIFFICULT ISSUE, BUT USING THE
DATA THAT'S ALREADY AVAILABLE
THROUGH THE EMR TO EXPLORE
DISPARITIES IN A NUMBER OF
DIFFERENT WAYS, T HOW TO MINE
THAT, HOW TO GET PAST THE
BARRIERS ARE SOMETHING THAT I
THINK WOULD BE IMPORTANT TO
INVESTIGATE BECAUSE THERE'S
PROBABLY A WEALTH OF INFORMATION
THERE THAT WE COULD USE.
KAREN MENTIONED THE IDEA OF THE
CERTIFICATION PROCESS, USING
THAT TO HELP US GET TO THAT DATA
BY IN SOME WAY REQUIRING
APPROPRIATE DATA COLLECTION THAT
MAY ALREADY BE THERE, BUT TO
MAKE IT AVAILABLE IN WAYS THAT
WE CAN ACCESS TO LOOK AT THESE
ISSUES OF DISPARITIES.
AND THEN THE TELEREHAB, WHICH IS
ONE AREA THAT OUR GROUP
CONSISTENTLY IDENTIFIED AS AN
AREA OF DISPARITIES WITH POST
HOSPITAL CARE AND THE USE OF
INPATIENT REHAB VERSUS HOME
HEALTH VERSUS SKILLED NURSING
AND SO ON, AND TELEREHAB IS A
WAY THAT WE MIGHT BE ABLE TO GET
PAST SOME OF THOSE ISSUES BY
DELIVERING REHABILITATION
THERAPY AT HOME.
SO THAT'S THE END OF OUR
PRESENTATION FOR OUR GROUP.
SO THANK YOU TO YOU AND TO
EVERYONE IN OUR GROUP FOR THEIR
GREAT PARTICIPATION.
>> THANK YOU, KAREN, THANK YOU,
LARRY.
GREAT DISCUSSION, GREAT SUM-UP.
LET'S OPEN THIS UP FOR COMMENTS,
SUGGESTIONS.
IDEAS.
LOOKING IN CHAT TO SEE IF
ANYBODY HAS THEIR HANDS UP.
KAREN AND LARRY, YOU ALL BOTH
MENTIONED SEVERAL TIMES,
RIGHTFULLY SO, THE ISSUE OF
STANDARDIZATION OF CARE AND
SHARING OORD SET ORDER SETS AND THINGS
LIKE THAT.
WHAT DO YOU THINK ARE BARRIERS
TO DO THAT?
I KNOW WITHIN HOSPITAL SYSTEMS,
HOPEFULLY THAT'S GOING ON
ROUTINELY, BUT HAVE YOU
IDENTIFIED OR EXPERIENCED
BARRIERS TO DO THAT WITHIN YOUR
STATE, YOUR SYSTEM, YOUR REGION?
I THINK IT'S
>> I HAVE NOT.
I THINK IT'S MORE GETTING
PEOPLE'S ATTENTION AND HOW
IMPORTANT IT IS WE ELIMINATE
INEQUITIES AND USE OF PROTOCOLS
THAT ARE EVIDENCE-BASED REALLY
HELPS THE HEALTHCARE SYSTEM
ACHIEVE THAT.
>> I AGREE.
I DON'T THINK PLACES WOULD BE
TERRIBLY RESISTANT TO IT.
I THINK IT'S MORE A MATTER OF
FOCUS THAT I THINK IN A LOT OF
HUB AND SPOKE TELESTROKENET
WORKS, FOR EXAMPLE, THE FOCUS
HAS BEEN ON DECISION ON
REPERFUSION THERAPY AND NOT
CONCENTRATING ON WHAT GOES ON
AFTER THAT.
I THINK IF WE COULD JUST CHANGE
THAT FOCUS AND CONTINUE THE
SUPPORT OF OUR SPOKE HOSPITALS
THROUGHOUT THE SPECTRUM OF NOT
ONLY E.D. AND ACUTE STROKE CARE
BUT HOSPITAL CARE, MAYBE EVEN
POST STROKE DISCHARGE, THAT
WOULD BE SOMETHING THAT COULD
REALLY HELP THE SITUATION.
>> JUSTIN, DID YOU WANT TO SAY
SOMETHING?
>> I JUST WONDER, IS THERE AN
AVENUE HERE WHERE -- COULD WE
PARTNER WITH COMPANIES LIKE HE
PICE.EPIC, HOSPITALS COULD CHOOSE TO
ADOPT OR NOT ADOPT THEM BUT
THERE'S SOME FRAMEWORK THAT'S
JUST EASY TO GIVE TO ANY
HOSPITAL THAT HAS THAT EMR
SYSTEM AND WORK WITH THE BIG
COMPANIES, YOU KNOW, THAT HAVE
THAT, SO AT LEAST THERE'S A
LAUNCHING PLATFORM THAT EVERY
HOSPITAL CAN USE TO THEN MAKE
THESE EDITS.
>> I THINK THAT'S A GREAT
SUGGESTION.
I DON'T KNOW HOW MANY OF YOU ARE
ON EPIC.
WE ARE HERE IN CONNECTICUT.
AND UNBEKNOWNST TO ME BUT AS I
STARTED WORKING MORE AND MORE
WITH EPIC, EPIC HAS A LOT OF
MODULES ALREADY BUILT INTO IT,
THAT THEY DON'T PUBLICIZE.
LIKE THEY HAVE A MODULE TO DEAL
WITH DEPRESSION CALLED SAD, AND
THEY HAVE A MODULE TO DEAL WITH
CHILDBIRTH CALLED STORK.
FOR SOME REASON, THEY DON'T LET
EVERYBODY KNOW ABOUT THIS, BUT
IT'S A WELL-KEPT SECRET.
SO IF YOU'RE ON EPIC OR ANOTHER
EMR, I THINK THE STARTING PLACE
IS TO ASK THEM, HEY, WHAT
MODULES ARE ALREADY BUILT IN TO
YOUR EMR SO YOU DON'T HAVE TO
REINVENT THE WHEEL?
SO I FOUND THAT EYE OPENING
BECAUSE THE EPIC PEOPLE AT LEAST
ARE NOT AS FORTHCOMING WITH THIS
AS YOU WOULD HOPE THEY WOULD BE.
>> MARK, JUST ONE QUICK COMMENT
RELATING TO SOMETHING THAT LARRY
SAID.
IN THE V.A. TELESTROKENET WORK,
WE HAVE REALLY FOCUSED ON ACUTE
CARE.
WE ARE NOW EXPLORING, STARTING
WITH A FEW RURAL HOSPITALS THAT
HAVE NO NEUROLOGISTS ON THEIR
STAFF, AT LEAST NOT FOR
INPATIENT CARE, TO DO SORT OF A
RAPID TIA CLINIC AND THEN EARLY
FOLLOW-UP BEFORE DISCHARGE FOR
SECONDARY PREVENTION.
THAT'S NEW.
THERE WERE ADVANTAGES AND
DISADVANTAGES TO THE NETWORK,
BUT IT DOES HELP TO BALANCE OUT
PEAK CAPACITY WHEN THINGS ARE
LESS BUSY BY HAVING PROVIDERS DO
THINGS THAT HAVE MORE
FLEXIBILITY IN SCHEDULING.
IT DOES REQUIRE A VERY DIFFERENT
WORKFLOW THAN HYPERACUTE CARE,
AND SO IT HAS BEEN A BIT MORE
CHALLENGING, AT LEAST IN THIS
SYSTEM, TO IMPLEMENT, BUT I
THINK YOU'RE CORRECT IN THAT IT
IS NOT QUITE ENOUGH FOR MANY OF
OUR RURAL HOSPITALS,
PARTICULARLY THOSE THAT ARE
ISOLATED FROM ANY INPATIENT
NEUROLOGIC EXPERTISE, TO JUST
FOCUS ONLY ON THE ACUTE CARE,
EVEN IF THEY TRANSFER OUT ALL
STROKES, THERE'S THE TIAs,
THERE'S THE PATIENT THAT COMES
BACK FOR SOMETHING ELSE BUT
THEIR SECONDARY PREVENTION HAS
BEEN -- YOU KNOW, THE BALL HAS
BEEN DROPPED, AND THINK THIS IS
A VERY IMPORTANT ASPECT FOR
SMALLER HOSPITALS AND RURAL
CARE, WHERE PEOPLE DON'T HAVE
ACCESS TO VASCULAR NEUROLOGY BUT
THEY DON'T HAVE ACCESSORILY TO
ANY NEUROLOGY IN SOME CASE.
>> AND I THINK, GLEN, TO EXPAND
ON WHAT YOU'RE SAYING, IT CAN
CHANGE THE DYNAMIC OF THE
TRANSFER SITUATION, BECAUSE
HOPEFULLY FEWER PATIENTS NEED TO
BE TRANSFERRED IF THERE'S NO
NEUROLOGY EXPERTISE, IF THERE'S
NO STROKE EXPERTISE, THEN
THEY'RE MORE LIKELY TO TRANSFER
THAT PATIENT, BUT IF YOU'RE
DELIVERING THAT EXPERTISE BY
TELEMEDICINE, MAYBE THEY FEEL
MORE COMFORTABLE KEEPING THE
PATIENT AT THE HOSPITAL, AND
TIAs AND MINOR STROKES AND LA
KUHNS FOR WHICH THOSE PATIENTS
ARE TRANSFERRED THAT WE DON'T DO
A WHOLE LOT OF AT THE COMMUNITY
HOSPITAL ANYWAY, AND MAYBE THOSE
PATIENTS COULD STAY AT THE
COMMUNITY HOSPITAL AND THE
STROKE CENTERS WHICH ARE
BASICALLY -- WE'RE ALL
OVERWHELMED WITH STROKE
PATIENTS -- DON'T HAVE TO GET
ALL THESE PATIENTS THAT WE'RE
NOT GOING TO DO ANYTHING
TERRIBLY DIFFERENT FOR, AS LONG
AS THEY CAN STILL HAVE THE
STROKE EXPERTISE FOR MAKING SURE
THEY GET THE PROPER WORKUP AND
THE DECISIONS ARE MADE FOR
SECONDARY STROKE PREVENTION UPON
DISCHARGE BY SOMEONE WITH STROKE
EXPERTISE BY TELEMEDICINE.
AND THEN THERE'S ALSO THE
HEMORRHAGES WITH VERY SMALL
HEMORRHAGES AND VERY LARGE
HEMORRHAGES, WHICH PERHAPS IF
THERE'S STROKE SUPPORT BY
TELEMEDICINE, MAYBE THOSE
PATIENTS DON'T REALLY NEED TO BE
TRANSFERRED AS WELL.
SO I THINK THERE ARE SOME BIG
ADVANTAGES.
THE DISADVANTAGE IS THAT IT IS
TIME-INTENSIVE, AND AGAIN, IT'S
RESOURCE-INTENSIVE FOR THE
PROVIDERS.
IT'S JUST ANOTHER ADDED BURDEN
FOR THE STROKE DOCTORS IN
ADDITION TO EVERYTHING THAT
THEY'RE ALREADY DOING TO BE
SEEING THESE PATIENTS AT
MULTIPLE COMMUNITY HOSPITALS
ONCE OR TWICE OR WHATEVER THAT
BURDEN IS, AND SO THOSE THINGS
HAVE TO BE BALANCED, BUT I THINK
THE POSSIBILITIES ARE THERE.
>> SURE.
JUST A FEW COMMENTS ON THAT FROM
OUR EXPERIENCE.
FIRSTLY, YOU'RE ABSOLUTELY RIGHT
IN THAT IN THE ABSENCE OF THE
ABILITY TO GET A NEUROLOGY
CONSULT OR SHORT TERM NEUROLOGY
FOLLOW-UP, THERE'S A TENDENCY OF
COMMUNITY HOSPITALS TO WANT TO
SEND -- YOU KNOW, OUT OF
MEDICAL-LEGAL OR OTHER FEAR, TO
SEND EVERYTHING OUT.
THIS CAN REPRESENT MILLIONS OF
DOLLARS OF COST PER YEAR FOR A
LARGER BUT STILL COMMUNITY
HOSPITAL, NON-COMPREHENSIVE
STROKE CENTER.
WE HAVE STUDIED THIS BOTH
ANECDOTALLY, A FEW OF OUR V.A.S,
WE HAVE A PAPER IN PRESS OF JUST
THIS POINT, THAT IT CLEARLY
REDUCES TRANSFER EVEN THOUGH WE
DON'T -- I THINK YOUR POINT IS
WELL TAKEN.
>> LARRY, THE OTHER ASPECT OF
THIS I LEARNED WORKING WITH THE
JOINT COMMISSION IS OBVIOUSLY
THINGS LIKE TPA AND EVT, IT'S A
TIME-SENSITIVE TRIAGE DECISION.
BUT WHAT THEY TAUGHT ME FROM
THEIR EXPERIENCE GOING TO MANY
THOUSANDS OF HOSPITALS IS THAT
IF A HOSPITAL IS DEFICIENT IN
ONE ELEMENT OF CARE, ODDS ARE
THAT THEY ARE DEFICIENT IN OTHER
ELEMENTS OF CARE EITHER.
IT SORT OF LIKE A RED FLAG FOR
THEM, THAT IF THEY DON'T HAVE
EXPERTISE HERE, THEY MAY NOT
HAVE EXPERTISE THERE.
SO SOME PATIENTS DO NEED TO BE
TRANSFERRED AND SOME PATIENTS
DON'T.
WHENEVER I'VE DONE
TELESTROKE-TYPE THINGS ABOVE AND
BEYOND THE HYPERACUTE TRE TRIAGE
DECISION, I'M ALWAYS A LITTLE
BIT CONCERNED THAT AM I ENABLING
A PATIENT TO BE IN A CARE
SETTING THAT ALMOST, BY
DEFINITION, HAS EVERYTHING THEY
NEED.
DOES THAT APPLY TO EVERY PATIENT
IN EVERY SETTING?
OF COURSE NOT.
BUT THE FACT THAT WE'RE
PROVIDING TELESTROKE SERVICES
ABOVE AND BEYOND THE HYPERACUTE
SETTING, IT JUST ALWAYS MADE ME
A LITTLE BIT UNEASY THAT I WAS
SORT OF ENABLING HOSPITAL TO
MAYBE NOT GET UP TO THE LEVEL OF
CARE THAT THEY SHOULD BE GETTING
UP TO, AND IT GOES BACK TO A
THING WE SPOKE ABOUT YESTERDAY,
AND THE BAC HAS DONE THIS, THE
AHA AND OA SET EGG STANDARDS OF
CARE.
THIS IS THE STANDARD OF CARE FOR
TPA, CARDIOEMBOLIC STROKE OR
WHATEVER IT MAY BE.
IT'S UP TO US IN THE HOSPITALS
TO FIGURE OUT HOW THEY'RE GOING
TO MEET THAT STANDARD OF CARE,
NOT TO LOWER THE STANDARD OF
CARE BECAUSE THEY'RE AT LOCATION
A, B OR C.
I THINK THAT' THAT SORT OF IS A SELF
PERPETUATING CYCLE WHERE THEY'RE
NOT DOING ALL THAT THEY COULD OR
SHOULD DO.
>> SO I GET YOUR POINT, MARK.
THAT'S A GOOD POINT.
BUT I WOULD JUST COMMENT FURTHER
THAT THERE'S NO PERFECT SOLUTION
OBVIOUSLY, BUT I THINK THE
QUESTION IS, CAN WE BRING THE
STANDARD OF CARE AT A COMMUNITY
HOSPITAL UP TO WHERE WE WANT IT,
AND WHAT IT SHOULD BE, OR WHAT
IT IS AT A STROKE CENTER BY
SUPPORTING THEM IN THESE WAYS?
NOT JUST TELEMEDICINE, BUT THE
ORDER SETS, THE PATHWAYS, ALL OF
THAT TOGETHER, CAN WE BRING IT
UP TO A GOOD STANDARD.
BECAUSE IT'S JUST IMPRACTICAL
FOR ALL OF THESE STROKE PATIENTS
TO BE SENT TO OUR HOSPITALS.
WE'RE OVERWHELMED, THE STROKE
DOCTORS ARE OVERWHELMED,
EVERYBODY'S BURNED OUT.
THE CALL IS JUST GETTING
RIDICULOUS.
AND TO THE EXTENT THAT WE
HAVE -- YOU KNOW, THERE ARE
CERTAINLY PATIENTS WHO NEED TO
COME IN TO OUR HOSPITALS.
THE PATIENTS WHO GET
ENDOVASCULAR THERAPY, THE
PATIENTS WHO MAY HAVE A LEM RAJ
THAT COULHEMORRHAGE WHO NEED SURGERY,
PATIENTS WHO NEED DECOMPRESSIVE
HEMIECTOMIES.
BUT THERE ARE SOME THAT DON'T
NEED TO COME DOWN TO US THAT
COULD BE CARED FOR STILL IN THE
COMMUNITY, AND I THINK THAT
WOULD HELP THIS PROBLEM OF THE
OVERWHELMED STROKE CENTERS,
NUMBER ONE, BUT IT'S ALSO BETTER
FOR THE PATIENTS IF THEY GET
GOOD CARE TO STAY IN THEIR
COMMUNITY WHERE THEIR FAMILIES
ARE, WHERE THEY FEEL
COMFORTABLE, AND SO ON.
SO HOPEFULLY IT COULD BE A
WIN-WIN FOR EVERYBODY.
>> SURE, I AGREE, LARRY,
ABSOLUTELY, JUST TO MAKE A
COUPLE MORE POINTS.
ANOTHER THING WE CAN DO FOR
SITES IS ONGOING EDUCATION.
AND I THINK THAT'S VITAL TO
RAISE THE LEVEL OF CARE IN A
HOSPITAL THAT HAS LIMITED
EXPERIENCE WITH STROKE PRIOR.
BUT YOU ALSO RAISE THE QUESTION,
WHICH IS PARTICULARLY ACUTE IN
RURAL AREAS, SOMETIME IN A
REGION THERE MAY BE JUST ONE
STROKE CENTER.
IT MAY NOT EVEN BE A FULL
COMPREHENSIVE STROKE CENTER.
HOSPITALS ARE OFTEN VERY
COMFORTABLE WITH THE ISSUE THAT
WE SEND EVERY SINGLE STROKE,
POSSIBLE STROKE, MIGHT BE A
STROKE, OUT.
THIS CAN ABSOLUTELY OVERWHELM A
REGIONAL SYSTEM.
WUNL OF THE FIRST PATIENTS WE
TREATED WAS BECAUSE THE REGIONAL
STROKE CENTER REFUSED TO
TRANSFER BECAUSE THEY WERE
ABSOLUTELY ABOVE CAPACITY.
AND WE'VE HAD THIS OCCASION.
SO I THINK THE DEFAULT OF WE
DON'T TREAT STROKE HERE, WE'RE
GOING TO SEND ABSOLUTELY
EVERYBODY OUT, REALLY CAUSES AN
UNDUE PRESSURE AND HAS LIKELY
MORE NEGATIVE CONSEQUENCES FOR A
PATIENT POPULATION THAN A
NUANCED APPROACH.
>> I ALSO THINK IT'S FAIR THAT
WE DON'T PAINT ALL OF THESE
CENTERS WITH THE SAME BRUSH.
SOME OF THEM HAVE DIFFERENT
SUPPORT NETWORKS AND SUPPORT
SYSTEMS, AND IT'S PROBABLY
UNFAIR AND UNWISE TO PAY THEM,
JUST LIKE PRIMARY CARE
PHYSICIANS THAT YOU AND I DEAL
WITH ALL THE TIME.
SOME OF THEM PRACTICE AT A VERY
HIGH LEVEL, SOME OF THEM ARE
SORT OF MEDIOCRE, AND SOME OF
THEM DON'T DO A GOOD JOB WITH
SECONDARY STROKE PREVENTION.
THERE'S VERY LACKADAISICAL.
SO I AGREE, IT'S UNFAIR TO PAINT
THEM ALL WITH ONE BRUSH.
OTHER COMMENTS OR QUESTIONS?
WE HAVE ABOUT 45 OR 50 PEOPLE ON
THE CALL.
THIS IS YOUR CLANS TO PROVIDE
INPUT.
CHANCE TO PROVIDE
INPUT.
RICHARD, ANY PERSPECTIVES FROM
YOUR POINT OF VIEW?
HAVE WE DONE A SUFFICIENT JOB
TOUCHING ON DISPARITIES AND LACK
OF EQUITY AMONG DIFFERENT
POPULATIONS, DIFFERENT GROUPS?
>> I THINK THIS HAS BEEN A
REALLY EXCELLENT DISCUSSION, AND
DISTILLATION OF EVERYTHING THAT
WAS PRESENTED ON YESTERDAY.
I'M JUST HERE TAKING NOTES AND
SENDING INFORMATION BACK AND
FORTH ABOUT SOME OF THE
WONDERFUL DISCUSSIONS THAT WE'VE
HAD.
AND I THINK THIS IS GREAT.
SO I'M OPENING TO OTHER PEOPLE
TO OFFER THEIR COMMENTS.
>> GOING ONCE, GOING TWICE?
WE'VE ASSEMBLED A FEW SUMMARY
SLIDES THAT IF RICHARD AND SAM
AGREE, PROBABLY BETTER JUST TO
EMAIL TO YOU INSTEAD OF GOING
THROUGH THEM ONE BY ONE, BUT WE
HAVE CAPTURED SOME OF THE
SUMMARY POINTS OF THIS MORNING'S
DISCUSSIONS.
TRYING TO DO THESE SLIDES ON THE
FLY IS ALWAYS CHALLENGING, AND
YOU KNOW, WE CAN GO OVER THEM
AND SEND THEM OUT TO YOU EARLY
NEXT WEEK.
JUST A SUMMATION IF THAT'S
AGREEABLE TO RICHARD AND SAM.
ARE YOU OKAY WITH THAT?
>> MARK, WE CAN UPDATE THE
MEETING WEBSITE AND PUT THE
INFORMATION THAT'S ON THE SLIDES
ON THE MEETING WEBSITE, BUT
WE'RE UNLIKELY TO ACTUALLY
DISTRIBUTE THE POWERPOINT
DEMONSTRATION ITSELF, BUT IT
WILL STILL BE ACCESSIBLE TO
EVERYONE AFTER THE FACT.
>> WONDERFUL.
SO SAM, DO YOU WANT TO GO OVER
NEXT STEPS IN TERMS OF
PUBLICATIONS, FOLLOW-ON MEETINGS
AND THE LIKE?
>> RIGHT.
SO SOME OF YOU ARE ALREADY A BIT
AWARE OF THE ANTICIPATED
PROCESS, BUT OTHERS, I THINK,
ARE NOT, SO JUST TO DO A STEP
BACK OR TWO, YOU KNOW, THE IDEA
FOR THE SYMPOSIUM AROSE WITH THE
BRAIN ATTACK COALITION AS THEY
WERE KIND OF THINKING ABOUT
REALLY, YOU KNOW, IMPACTFUL
TOPICS TO CONSIDER.
AND THIS WAS ACTUALLY A COUPLE
YEARS A WHEN THE IDEA FIRST
SURFACED, SO THEN WE ENDED UP
EVENTUALLY DEVELOPING A STEERING
COMMITTEE AND THEN THE THREE
TASK FORCES OF WHICH WE'VE HEARD
FROM EXTENSIVELY OVER THE PAST
TWO DAYS.
AND THOSE GROUPS OF ALL DIVERSE
SPEAKERS AND EXPERTS, PEOPLE ALL
ACROSS THE COUNTRY, PEOPLE FROM
DIFFERENT SECTORS, THEY ARE THE
ONES WHO DID ALL OF THE HUGE
LEGWORK TO LEAD TO THE
PRESENTATIONS THAT YOU SAW
YESTERDAY, AND OF COURSE THEY
WERE LED BY ALL OF OUR FANTASTIC
TASK FORCE LEADS, AND WORKED
CLOSELY WITH THE STEERING
COMMITTEE, PARTICULARLY MARK AND
RICHARD, TO DO THE DRAFT REPORT
THAT WE HAVE ALL BEEN
DISCUSSING.
SO NOW WHAT IS GOING TO HAPPEN
IS, UNLESS ANYONE HAS ANYTHING
ELSE THEY WANT TOE TO ADD TODAY, WE
ARE GOING TO END OUR SYMPOSIUM
WITH YOU AFTER YOUR INSIGHTS.
WE HAVE SCIENCE WRITERS WHO HAVE
BEEN TAKING VERY DETAILED NOTES
FROM ALL THE DIFFERENT
DISCUSSIONS, AND ALL OF THIS
INFORMATION IS GOING TO GO BACK
TO THE STEERING COMMITTEE AND
THE TASK FORCES SO THEY ARE ABLE
TO MAKE SOME TWEAKS, ADDITIONS,
ET CETERA, TO THE DRAFT REPORT
WE POSTED ON MEETING WEBSITE IN
THE COMING MONTHS.
THE GOAL IS TO HAVE KIND OF A
REVISED AND FINAL VERSION OF THE
LONG FORM REPORT BY THIS SUMMER,
PREFERABLY BY MID, LATE JUNE
PERHAPS.
AND AND POTENTIALLY A SHORTER
FORM KIND OF COMMENTARY THAT HAS
THE HIGHLIGHTS AT MORE OF AN
EXECUTIVE SUMMARY FROM ALL OF
THESE DISCUSSIONS AND FROM THE
WHOLE REPORT, AND THEN REALLY
KIND OF POINTS OUT SOME VERY
TANGIBLE SHORT TERM AND LONG
TERM ACTION ITEMS FOR THE ENTIRE
STROKE COMMUNITY TO CONSIDER IN
THIS SPACE, AND THAT WILL GO
BACK TO THE BRAIN ATTACK
COALITION, WHICH IS AGAIN FOR
THOSE OF WHO YOU DON'T KNOW A
KIND OF PUBLIC AND PRIVATE
COALITION INVOLVES AN ASSORTMENT
OF FEDERAL AGENCIES, NON-PROFIT
ORGANIZATIONS AND PRIVATE
ORGANIZATIONS AND HOSPITAL
SYSTEMS AND THEY WILL REVIEW
EVERYTHING AND BASICALLY ARE
GOING TO BE THE COLLECTIVE
APPROVERS, AND THEN FROM THERE,
WE AT NINDS WILL BE POSTING THE
FULL REPORT, THE LONG FORM
REPORT ON ONE OF OUR WEBSITES,
SO IT IS NICE AND ACCESSIBLE.
AND THEN WE WILL LOOK INTO
PUBLISHING THE SHORTER FORM IN A
JOURNAL THAT IS STILL TO BE
DETERMINED, BUT WE REALLY DO
WANT TO MAKE SURE THAT THERE ARE
MULTIPLE WAYS FOR PEOPLE TO
ACCESS THIS INFORMATION, AND WE
ALSO, OF COURSE, IN THE
GOVERNMENT WANT TO MAKE SURE
THAT THE FULL DETAILS CAN BE
ACCESSIBLE THAT ARE NOT BEHIND
ANY SORT OF PAY WALL OR ANYTHING
LIKE THAT.
SO THESE ARE THE NEXT STEPS THAT
WE ARE GOING TO WORK THROUGH IN
THE COMING MONTHS.
SO STAY TUNED.
I THINK WHAT I CAN DO IS I WILL
PUT IN THE CHAT MY EMAIL SO I'M
THE CHIEF SCIENTIFIC AND PUBLIC
ENGAGEMENT AT NINDS, SO IF ANY
MEMBERS OF THE ATTENDEES TODAY
AND WE CAN UPDATE THE WEBSITE
WITH THIS TOO, IF YOU HAVE
ADDITIONAL IDEAS THAT COME TO
YOU FROM ALL THESE DISCUSSIONS
AND ALL THAT YOU'VE HEARD, IF
YOU GO BACK TO THE DRAFT REPORT
AND ARE REREADING IT A LITTLE
MORE CAREFULLY WITH THE
SYMPOSIUM PRESENTATIONS AND
DISCUSSIONS IN MIND, AND YOU
HAVE NEW IDEAS, DO FEEL FREE TO
SEND THEM OUR WAY AND I'M HAPPY
TO MAKE SURE THEY GET
DISTRIBUTED TO THE BRAIN ATTACK
COALITION, OUR STEERING
COMMITTEE AND THE THREE TASK
FORCES.
SO INTO THE CHAT.
I'M ALSO A PUBLIC SERVANT SO YOU
CAN FIND ME ON THE INTERNET,
SAMANTHA WHITE IS MY NAME IF YOU
MISS THIS, AND I THINK THAT IS
IT, MARK AND RICHARD, FROM ME.
>> THE OTHER THING WE'RE GOING
TO DO, SAM, AND AGAIN, THANK YOU
AND YOUR STAFF FOR ALL OF YOUR
HARD WORK AND SUPPORT, OBVIOUSLY
NINDS IS PART OF THE BAC AND
MEMBERS OF NINDS, YOU HEARD FROM
DR. KOROSHETZ YESTERDAY, CLINT
WRIGHT WAS ON FOR PART OF
YESTERDAY, NOT SURE IF HE WAS ON
TODAY, SCOTT JANIS WORKS
ACTIVELY WITH THE BAC.
WE WILL SHARE WITH THEM THE
RESULTS OF THE VARIOUS TASK
FORCES AND THE FINAL PUBLICATION
TO WORK WITH THEM AND IDENTIFY
WITH RICHARD'S SUPPORT
OBVIOUSLY, FUNDING
OPPORTUNITIES.
BE IT RFAs OR RFPs OR THINGS
THAT COULD LEAD TO TESTABLE
HYPOTHESES THAT HOPEFULLY WE CAN
WORK WITH GROUPS AND OTHER
PEOPLE TO WRITE GRANT PROPOSALS
THAT COULD GET FUNDED THROUGH
EITHER A NORMAL MECHANISM OR A
SPECIAL MECHANISM TO SUPPORT AND
ANSWER SOME OF THE GREAT
QUESTIONS AND SEEK SOLUTIONS TO
THE INEQUITIES AND DISPARITIES
THAT WERE IDENTIFIED OVER THE
PAST TWO DAYS.
>> AND JUST A QUICK POINT OF
CLARIFICATION ON THAT, SO THE
WAY THAT NINDS CREATES FUNDING
OPPORTUNITIES IS A VERY
REGULATED PROCESS, SO OF COURSE
ALL OF THE INFORMATION FROM THE
SYMPOSIUM AND THAT COMES OUT IN
THE FINAL REPORT, THE SHORT FORM
OF THE REPORT WILL BE
DISTRIBUTED BROADLY TO ALL
MEMBERS, ALL STAKEHOLDERS OF
NINDS, ALL THOSE INVESTED IN
STROKE, AND THEN ALONG THE WAY,
OUR PROGRAM STAFF AND OUR
LEADERSHIP SEPARATELY, ON THEIR
OWN, KIND OF GATHER INFORMATION
FROM THE STATE OF THE FIELD,
FROM CONVERSATIONS JUST LIKE
THESE, AND THEN WE SEPARATELY
COME UP WITH IDEAS.
THEY'RE CALLED FUNDING
OPPORTUNITY CONCEPTS, THAT THOSE
ACTUALLY HAVE TO DID TO OUR
FEDERAL ADVISORY COUNCIL FOR
APPROVAL, AND THEN UPON THAT
APPROVAL, THE PROGRAM STAFF CAN
START TO CREATE THESE FUNDING
OPPORTUNITIES, AGAIN WITH THEIR
EXPERIENCE AND EDUCATION FROM
OUR ENTIRE PORTFOLIO, FROM OTHER
WORK, RICHARD'S OFFICE HAS DONE
A HUGE AMOUNT OF WORK IN
STRATEGIC PLANNING IN THIS SAME
AREA, SO CERTAINLY INFORMED BY
THAT, AND THEN, OF COURSE, ONCE
WE HAVE ACTUALLY PUBLISHED
THOSE, THEY'RE PUBLISHED
PUBLICLY IN THE NIH GUIDE, AND
WE WILL CERTAINLY LOOP BACK TO
ALL ATTENDEES FROM THE SYMPOSIUM
TO LET YOU KNOW WHEN WE HAVE
OPPORTUNITIES FOR YOU TO APPLY
FOR THINGS.
BUT ALSO, THERE EVENTUALLY WILL
BE A APPROVAL FROM OUR COUNCIL
AND THAT ALWAYS HAPPENS IN THE
PUBLIC VERSION OF THAT MEETING.
SO THAT IS ALSO AN OPPORTUNITY
FOR YOU ALL TO REJOIN AND
ACTUALLY SEE THE CONCEPT THAT
OUR PROGRAM STAFF ARE ABLE TO
COME UP WITH ON THEIR OWN AND
SEE THE DISCUSSION THAT THEY
HAVE WITH OUR FEDERAL ADVISORY
COMMITTEE.
>> THANK YOU.
I DO WANT TO MAKE JUST A FEW
SHORT, BRIEF CLOSING REMARKS.
I'D FIRST LIKE TO THANK MARK FOR
YOUR GREAT LEADERSHIP, AND BEING
ABLE TO WORK BESIDE YOU IN
CO-CHAIRING THIS WORKSHOP THAT
WE'VE HAD THE LAST COUPLE OF
DAYS.
YOU'VE SHOWN GREAT LEADERSHIP.
I'VE LEARNED A LOT FROM YOU
DURING THIS PROCESS.
I'D ALSO LIKE TO THANK THE TASK
FORCE LEADS AS WELL AS THE TASK
FORCE MEMBERS FOR ALL OF THE
HARD WORK THAT YOU'VE DONE IN
TERMS OF PULLING THIS
INFORMATION TOGETHER, DOING THE
RESEARCH, AND THE PRESENTATION
THAT YOU'VE DONE TODAY.
SAM, HER LEADERSHIP AND HER
OFFICE FOR EVERYTHING THAT
THEY'VE DONE, I'M REALLY
GRATEFUL FOR THAT.
AND CLINT IS ON, AND SO WE'VE
ALREADY JUST SORT OF
INCORPORATED SOME OF THE
INFORMATION AND WE'VE THOUGHT
ABOUT SOME OF THE THINGS THAT
YOU'VE TALKED ABOUT, AND SO SOME
REALLY EXCITING THINGS AND SAM
SORT OF WENT THROUGH AND
OUTLINED THE PROCESS.
SO WE'RE REALLY EXCITED AT
WORKING WITH YOU AND ALL MEMBERS
OF THE BRAIN ATTACK COALITION
FOR ALL OF THE HARD WORK THAT
YOU'VE DONE, AND WE LOOK FORWARD
TO ITING TO WOR CONTINUING TO WORK WITH YO U.
>> SO THANK YOU ALL VERY MUCH
FOR YOUR TIME AND DISCRETIONARY
EFFORT.
I KNOW THERE'S A LOT GOING ON
WITH PANDEMIC AND NATIONAL
MEETINGS AND THINGS LIKE THAT,
AND I THINK FOR MANY OF US, THIS
IS A LABOR OF LOVE THAT HAVE A
CAREER RELATED TO STROKE
TREATMENT, STROKE PREVENTION AND
STROKE RECOVERY.
SO AGAIN, CAN'T THANK YOU ALL
ENOUGH, AND AGAIN, PLEASURE
WORKING WITH RICHARD AND SAM,
AND ALL OF THE PARTICIPANTS AND
TASK FORCE MEMBERS.
I THINK THIS IS THE SORT OF
EFFORT THAT WILL PAY DIVIDENDS
FOR YEARS TO COME.
MUCH AS THE NINDS SYMPOSIUM
RIGHT AFTER TPA GOT APPROVED HAS
REALLY PAID DIVIDENDS FOR
DECADES IN TERMS OF OFFERING
SOME GUIDANCE AND SOME FOUNDING
PRINCIPLES FOR HOW WE'RE GOING
TO USE THAT THERAPY AND NOW THIS
IS THE NEXT ITERATION OF THAT
WITH THE ADDED LAYER OF REALLY
FOCUSING ON DISPARITIES AND
INEQUITIES IN STROKE CARE AND
TREATMENT.
SO AGAIN, THANK YOU ALL VERY
MUCH.
HOPE YOU ALL HAVE A GREAT
WEEKEND, AND A SAFE SUMMER, AND
WE WILL BE BACK IN TOUCH WITH
YOU IN PROBABLY A FEW MONTHS
WITH A DRAFT FOR YOU TO REVIEW
AND THEN FURTHER FEEDBACK AND
THEN PUBLICATION ON A WEBSITE
AND HOPEFULLY IN A JOURNAL.
>> THANK YOU, MARK.
AND I DO WANT TO JUST ALSO GIVE
KUDOS TO THE OTHER MEMBERS OF
THE NINDS TEAM AND OUR LOGISTICS
CONTRACTOR WHO HAVE BEEN WORKING
TIRELESSLY TO SUPPORT ALL THE
TASK FORCES AND TO ACTUALLY RUN
THE SYMPOSIUM.
SO OUR CONTRACTORS, ROSALY AND
ASSOCIATES, THEY HAVE BEEN
FANTASTIC ALONG THE WAY AS WE
REALLY HAVE BEEN PULLING ALL THE
INFORMATION TOGETHER, GETTING
MEETING WEBSITE, RUNNING THE
ZOOM, THEY ARE DOING THIS.
THANKING VIDEOCAST MAKING SURE
THIS IS PUBLICLY ACCESSIBLE, AND
ARCHIVED SO YOU CAN PUBLICLY
VIEW THIS.
YOU CAN EXTEND MEETING LINK TO
YOUR COLLEAGUES AND THEY WILL
ALSO BE ABLE TO SEE IT EVEN IF
THEY COULDN'T ATTEND TODAY OR
WERE NOT REGISTERED.
I ALSO WANT TO THANK MY NINDS
COLLEAGUES WHO WERE FACILITATING
EVERYTHING ALL ALONG, BUT EACH
OF THE TASK FORCES HAD SUPPORT
THAT CAME FROM ANDREA -- I'M
SORRY, IT DID COME FROM ANDREA,
BUT IT CAME FROM DIANA, RYAN,
AND CARLO, AND THEN ALSO WE HAD
OUR FABULOUS SCIENCE WRITER ON
STAFF, NINA, WHO HAS BEEN REALLY
DOING A HEROIC EFFORT IN TERMS
OF REALLY WRANGLING EVERYTHING
AND FORMATTING THE DRAFT REPORT
THAT YOU ALL SAW, AND SHE AND
CARLO WILL CONTINUE TO WORK WITH
THE TASK FORCES TO FORMAT THE
FINAL PRODUCT AS WE MOVE FORWARD
IN THE COMING MONTHS.
SO, WITH THAT, THANK YOU ALL,
THANK YOU, MARK, THANK YOU,
RICHARD, THANK YOU TO ALL OF OUR
TASK FORCES AND THE BAC, AND I
THINK WE CAN CLOSE OUT A BIT
EARLY.
>> THANK YOU ALL.
THANKS, SAM.
THANK YOU.
HAVE A GOOD WEEKEND.
>> BYE, EVERYONE.